WW24, vicinity Norfolk Island South Pacific, 2009

WW24, vicinity Norfolk Island South Pacific, 2009


On 18 November 2009, an IAI Westwind on a medevac mission failed to make a planned night landing at Norfolk Island in unanticipated adverse weather and was intentionally ditched offshore because of insufficient fuel to reach the nearest alternate. The fuselage broke in two on water contact but all six occupants escaped from the rapidly sinking wreckage and were eventually rescued. The Investigation initially completed in 2012 was reopened after concerns about its conduct and a new Final Report in 2017 confirmed that the direct cause was flawed crew decision-making but also highlighted ineffective regulatory oversight and inadequate Operator procedures.

Event Details
Event Type
Flight Conditions
Flight Details
Type of Flight
Aerial Work
Intended Destination
Actual Destination
Take-off Commenced
Flight Airborne
Flight Completed
Phase of Flight
Missed Approach
Location - Airport
Inadequate Aircraft Operator Procedures, Ineffective Regulatory Oversight, Deficient Crew Knowledge-automation, PIC less than 500 hours in Command on Type, Unplanned PF Change less than 1000ft agl
Into water, No Visual Reference
Fatigue, Inappropriate crew response - skills deficiency, Ineffective Monitoring, Plan Continuation Bias, Procedural non compliance, Stress, Ineffective Monitoring - SIC as PF
Emergency Evacuation, Evacuation difficulties in Water
Damage or injury
Aircraft damage
Hull loss
Non-aircraft damage
Non-occupant Casualties
Occupant Injuries
Most or all occupants
Off Airport Landing
Causal Factor Group(s)
Aircraft Operation
Safety Recommendation(s)
Aircraft Operation
Investigation Type


On 18 November 2009 an IAI Westwind 1124A (VH-NGA) being operated by Australian charter company Pel-Air on a medevac flight from Apia, Samoa to Melbourne via an intended refuelling stop at Norfolk Island was unable to obtain sufficient visual reference to complete a night landing there despite making four successive non precision approaches. The Captain elected to carry out a controlled ditching offshore as there was by then not enough fuel left to reach the designated alternate and he was concerned that there may not be enough fuel left for the safe completion of another approach. The ditching was successful but the aircraft broke in two and the main part quickly became submerged. All six occupants managed to escape including, with assistance, the stretchered patient. Two of them sustained serious injuries and three minor injuries but the Captain was uninjured.

The actual and intended flights for which the accident aircraft and crew were tasked. [Reproduced from the Official Report]

An Investigation in two parts

An Accident Investigation was carried out by the ATSB and a 77 page Final Report was released on 30 August 2012 with a minor correction subsequently made to this the following day. Shortly after release of this Report, a television program questioned its findings and a Parliamentary Committee decided to commence an inquiry to examine the findings of the Report, the investigation process involved and related matters. The Committee’s report, released in May 2013, made a number of recommendations to the Australian Government, the ATSB and other government agencies which included that ATSB re-open the Investigation “with a focus on organisational, oversight and broader systemic issues”. The ATSB then asked the Canadian Transportation Safety Board (TSB) to conduct an independent peer review of their investigation methodologies and processes. This was carried out based on three completed ATSB investigations including the Norfolk Island one and was “finalised” on 1 December 2014. It noted that there had been “significant limitations” in the ATSB’s application of its processes during the Norfolk Island investigation, especially in respect of “insufficient collection of factual information” including but not limited to the decision not to recover the CVR or FDR from the wreckage. Three days later, the ATSB formally reopened the Investigation which then reviewed the evidence obtained during the original investigation process as well as collecting a substantial amount of new information. The work of the re-opened Investigation informs the remainder of this much-abbreviated account of the Norfolk Island event.

What Happened and its context

The flight was carried out for medevac purposes and was conducted in a transport category aircraft but under prevailing Australian regulations was classified as an aerial work operation. Aerial work operations are a category distinguished from passenger carrying charter and scheduled air transport operations. The four passengers on the accident flight were a doctor, a nurse, the patient and the spouse of the patient.

The Captain, who had been employed by Pel-Air since 2005, had a total of 4,347 flying hours which included 889 hours on type of which 298 hours were in command on type. He had previously, after 130 hours line training, qualified as a First Officer on the Operator’s SA-227 Metro night cargo operations and then, in September 2007 after 68 hours line training, as a First Officer on the Westwind. He subsequently failed Westwind command training in June 2008 after 98 hours and finally gained command five months later after further training. It was noted that all type conversion training at the Operator was carried out on the aircraft, not in a full flight simulator, and that he had obtained some simulator experience in 2004 during Second Officer training with “a major Australian airline (which) was discontinued after he did not meet the required standard on multiple exercises”. He had made four previous flights to Norfolk Island, all of which were air ambulance flights at night, as well as a number to similarly remote aerodromes since gaining command. The First Officer had joined Pel-Air in January 2008 as a First Officer and had subsequently failed command upgrade training earlier in 2009 after 95 hours line training. She had a total of 1,961 hours flying experience of which 656 hours was on type and had made three previous flights to Norfolk Island, two with the same Captain as the accident flight.

It was noted that the same aircraft and crew had positioned the previous night from Sydney to Apia after spending the day on Standby until the mission to Apia was notified. The aircraft arrived in Apia via Norfolk Island in the early morning after approximately 6½ hours flying time and the crew then had just under 8 hours off duty during the day prior to beginning preparations for the return night flight. Both flight crew reported considering that they had achieved adequate rest during the day but in the case of the Captain in particular, this was not supported by contextual evidence.

It was found that pre flight planning by the aircraft commander consisted of obtaining the 12 hour TAF for Norfolk Island whilst submitting the FPL. This indicated that the forecast weather conditions were above the landing and alternate minima, the latter meaning that the FPL did not have to include an alternate. The flight briefing officer who provided the TAF also noted a TREND for the final 3 hours of the TAF periods which detailed an expected deterioration but “when the briefing officer asked if the commander would like the details of the trend, he declined”. It was also noted that the commander did not request an en route forecast and “did not obtain any other meteorological information, NOTAMs or additional briefing information from the briefing officer”. Instead, he used the weather and NOTAM briefing information from the outbound flight from Sydney to Samoa when planning the return flight to Norfolk Island “because of difficulty accessing internet-based briefing resources”. The aircraft was refuelled to full main tanks but exceptionally, none was added to the tip tanks for the approximately 1470nm flight to Norfolk Island for reasons that “could not be fully determined”. It was noted that applying the methods outlined in the Pel-Air OM would result in a total fuel required greater than the capacity of the main tanks alone.

The First Officer was designated as PF and the Captain reported that once in the cruise at FL390, he had reviewed the fuel required for the remainder of the flight against the fuel remaining and recalled that the prevailing 80 knot headwind component was greater than the 50 knots he had expected and he had therefore adjusted engine thrust setting to achieve a more efficient but slower cruise speed to allow completion of the sector without using reserve fuel.

Two and a quarter hours into what the Captain expected would be about a 4 hour flight, a SPECI received for Norfolk Island from the Nadi IFISO disclosed an earlier deterioration in the weather than had been contained in the TAF with a current overcast at 1100 feet aal. This meant that although the minima for Norfolk Island used as an alternate were no longer satisfied, conditions were still above destination landing minima. At this time, the Investigation estimated that the aircraft was “about 644nm from Norfolk Island, 649nm from Noumea and 317nm from Nadi” with more than enough fuel on board to divert to Nadi or Noumea and land with the required fuel reserves unused.

However, as the flight progressed, unknown to the crew, the conditions were continuing to deteriorate and half an hour later, another SPECI gave the cloud as broken at 300 feet and overcast at 900 feet which was below landing minima. By this time, the aircraft had continued on track beyond the point where the flight crew reported they had been confident that the aircraft had sufficient fuel to reach Noumea. The crew indicated that their doubts about the feasibility of this diversion were based on uncertainty as to the wind component which might prevail given their experience of the greater than expected headwind component on track. However, the Investigation calculated that 10 minutes later, with about 435nm to go to Norfolk Island and Noumea about 500 nm away and Nadi 465nm away, the fuel remaining was still more than sufficient to divert to either, without using reserve fuel. The captain stated that he had “regularly estimated the Point of No Return (PNR) during the accident flight and had considered both Nadi and Noumea as potential diversions as the flight progressed but he “could not recall the position or time of the PNR”. The First Officer stated that it was the Captain’s job to monitor the PNR and “she could not recall any discussion about it during the flight”. There was also no discussion on the CVR recording about the PNR for a diversion to either Nadi or Noumea.

About half an hour out from Norfolk Island, it was possible to establish contact with the Norfolk Island UNICOM operator and the flight was given the present weather there as measured by the Automatic Weather Station (AWS). As earlier, this included broken cloud at 300 feet but in addition now included a prevailing visibility of 6000 metres. CVR data showed that following receipt of this report, both crew were evidently becoming “noticeably more anxious” about the weather conditions. However, the Captain stated that at that time, he remained confident that they would still be able to land as he was “expecting the actual cloud conditions would be better than those detected by the AWS”, noting that “if he had been really concerned he would have elected to take over as PF for the approach”. However, reports from the UNICOM Operator continued to give cloud below landing minima.

Beginning at 1000 UTC, 4¼ hours after takeoff from Apia, a sequence of 4 unsuccessful approaches were flown - see the illustration below. The aerodrome elevation was 371 feet. The first two approaches used the VOR approach to runway 29 with a MDA of 850 feet which, once at that level was breached marginally to no less than 750 feet but nothing was seen. The Captain took over as PF whilst the aircraft was at MDA on the first approach and remained in that role thereafter. The Captain stated that after the second approach, he had become “significantly concerned about their prospects for landing successfully”. He then flew a third approach using the VOR procedure for runway 11 which had an MDA of 750 feet but nothing was seen on that approach either.

The aircraft ground track on arrival at Norfolk Island showing the first approach (blue), second approach (green), third approach (purple) and fourth approach and ditching (red). [Reproduced from the Official Report]

Soon after commencing the missed approach from runway 11, the CVR recorded the Captain stating that they would have to ditch the aircraft. At this time the aircraft was heading south-southeast over the sea and away from the airport and as it did so, it was noted that it had passed within 1½ nm of the 919 ft spot height on a small island just off the main island at about the same height as its terrain. After several discussions about whether to ditch or try another approach, the Captain decided to make another approach to runway 29 whilst at the same time, the passengers were instructed by the First Officer to prepare for a ditching and did so.

The First Officer stated that at the start of the fourth approach, the fuel gauges indicated that about 200 lb remained - the Investigation subsequently calculated that there was “probably about 520 lb of fuel remaining”. At the end of the fourth approach when again nothing was seen, the Captain recalled seeing “between 0 and 100 lb indicated on each fuel quantity gauge”; 23 minutes had elapsed since the start of the first approach. The Captain turned the aircraft towards what he reported knowing was open sea with no islands and set up a descent. At a recorded 80 feet above the sea, this was stabilised at about 360 fpm with the landing gear up and the airspeed 108 knots (and decreasing). The First Officer called out heights of ‘40’, ‘30’ and ’10 feet and the aircraft hit the sea at an airspeed of 92 knots. Data from both the CVR and the FDR indicated there had been three impacts successively recorded as 3.24 g, 2.30g and 1.98 g although the peak values may have been higher than those recorded. The nurse seated at the rear of the aircraft stated that the first impact had “involved a very significant vertical force” and the First Officer stated that the aircraft nose had entered the water on the final impact which had resulted in a significant longitudinal deceleration. Both pilots stated that although the aircraft landing lights were on, they had not seen anything outside before hitting the water and so were unable to align the aircraft track with the sea swell.

The aircraft was subject to significant impact damage and the main door partially opened during the last impact after which the aircraft cabin rapidly began to fill with water entering through this gap and into the rear of the cabin through the breached cabin floor. Although the cabin lighting soon failed, all six occupants were able to escape. The Captain opened and departed through the left emergency exit, the doctor and nurse assisted the patient out of the right emergency exit and the patient’s husband and the First Officer followed out of the left emergency exit although by then, both reported having to swim up to reach the sea surface. The occupants had only three of the on-board life jackets with them and neither of the two aircrafts life rafts. It was noted that all occupants except the stretchered patient had been through wet drill training and Helicopter Underwater Evacuation Training (HUET). As the intended ditching area communicated by the flight crew was not understood by the Unicom Operator, there was a significant delay in locating the occupants who had to wait almost 1½ hours to be rescued.

The Re-opened Investigation and its Findings

Significantly, the original Investigation had decided not to recover the aircraft flight recorders, which included a 2 hour CVR. This decision had been based on a number of considerations including that:

  • all the occupants had survived and could be interviewed
  • the depth of the wreckage (48 metres) meant that recovery would be difficult and costly.
  • key items of evidence from the CVR, such as communications about weather conditions and fuel management would only be available for the final 2 hours of the flight
  • only a small number of parameters were recorded on the FDR.

After the Investigation was reopened the feasibility of recovering the recorders was revisited and following an underwater survey of the wreckage, a specialised salvage contractor was engaged to conduct a recovery operation. This involved excavating sand from the wreckage location, specialised diving to prepare the tail section of the aircraft for recovery and then lifting of the tail section to the surface to retrieve the recorders which was successful. Good quality data was downloaded from both recorders and provided a valuable new insight into the circumstances that had prevailed.

Very considerable new investigative effort was also applied to a range of other relevant issues including meteorological aspects, ATS issues, fuel planning and management, pilot training and checking at the Operator, the Operator’s approach to risk assessmentsafety management and fatigue risk management, ditching survival issues and the oversight of the Operator by the safety regulator.

Significant concerns were identified in a range of areas including but not limited to the Captain’s poor pre flight planning especially in relation to fuel and his equally poor in flight approach to risk management en route, a lack of sufficiently robust Standard Operating Procedures (SOPs) at the Operator and limitations in regulatory requirements.

Safety Analysis and Conclusions

After reviewing all the assembled evidence, the Investigation made a series of “final comments” which included, in summary, the following:

  • The accident involved a combination of multiple safety factors including the individual actions of the flight crew and ATS personnel, local conditions influencing the flight crew, weakness in some aspects of regulatory oversight and incomplete risk controls and safety management processes at the Operator.
  • The Investigation identified many other factors that increased the risk to safety but the evidence did not allow it to conclude that they contributed to the accident.
  • The accident involved a combination of rare events. For example, historically, weather conditions below landing minima at Norfolk Island were found to occur just 0.1 per cent of the time, the Operator conducted relatively few flights to Norfolk Island or similar destinations and it was rare for any of the Operator’s long-distance flights to such islands to depart with less than the maximum possible fuel endurance. It was also unlikely that both Nadi ATS and Auckland ATS would not provide all the relevant weather information to a flight crew and then that the crew themselves would not request it at the appropriate time.
  • Nevertheless, each of these ‘rare events’ increased aggregate risk and ultimately provided a context for the accident outcome. This highlights the importance for all ‘front-line’ personnel and their organisations of both minimising the chances of any of them occurring and by having sound practices, controls and processes in place to identify and manage the consequences if they do occur.
  • The fact that the Reopened Investigation identified (see below) 16 Safety Issues when the Original Investigation identified just two ‘Minor Safety Issues’ was due in part (only) to the amount of information gathered by the former and the depth to which it was analysed. The more effort or resources are applied to an investigation, the more problems are likely to be found.

Overall, it was concluded that a Fundamental Lesson for all flight crew, operators and regulators is “to recognise that un-forecast weather can occur at any aerodrome (and) consequently, there is a need for robust and conservative fuel planning and in-flight fuel management procedures for passenger-carrying transport flights to remote islands and isolated aerodromes”.

Seven Additional Safety Messages were also identified as:

  • Flight crew should discuss and consider options to manage threats when there is time available to do so.
  • Operators should ensure their flight crew proficiency checks assess the performance of all key tasks required of their flight crew.
  • Operators should not rely on informal risk controls for managing the performance of safety-critical tasks, particularly when there is a significant turnover of pilots in a fleet.
  • Operators of air ambulance flights should ensure medical personnel have clearly defined procedures and practical training for using the emergency equipment on board to ensure they can effectively assist a patient in the event of an emergency.
  • All organisations in safety-critical industries should use proactive and predictive processes to identify hazards in their operations.
  • Organisations that use a bio-mathematical model of fatigue (BMMF) as part of their fatigue risk management system should ensure they have a detailed understanding of the assumptions and limitations associated with such models.
  • Regulators should develop effective methods for obtaining, storing and integrating information about operators and the nature of their operations so they can develop effective surveillance plans.

Formally documented Investigation Findings

These were divided into ‘Contributing Factors’ (17), Other Factors that increased risk (19) and 6 ‘Other Findings’. Five of the ‘Contributing Factors’ and eleven of the ‘Other Factors which increased risk’ were classified as ‘Safety Issues’ requiring explicit attention.

In contrast, the Original Investigation had identified only three ‘Contributory Factors’, none of them classified as ‘Safety Issues’, four ‘Other Safety Factors’ of which two were classified as ‘Minor Safety Issues’ and three “Key Safety Findings”.

Contributory Factors:

  • Contrary to the consistent practice of the operator’s Westwind fleet, the long-distance flight to a remote island aerodrome departed without uploading the maximum possible amount of fuel prior to departure. Had the flight departed with the maximum amount of fuel, it is very likely the aircraft would have had sufficient fuel to divert from the top of descent or to hold at the remote island for a significant period of time.
  • The Captain’s pre-flight planning did not include many of the elements needed to reduce the risk of a long-distance flight to a remote island or isolated aerodrome. Limitations included:
    • miscalculating the total fuel required for the flight under normal operations
    • not obtaining relevant forecasts of upper-level winds and, in the absence of such forecasts, underestimating the potential headwind component
    • not calculating the additional fuel required to allow for aircraft system failures
    • not obtaining a current aerodrome forecast and NOTAMs for potential alternate aerodromes
    • not calculating a point of no return (PNR).
  • The operator’s Westwind pilots generally used a conservative approach to fuel planning, and the operator placed no restrictions on the amount of fuel that pilots uploaded. However, the operator’s risk controls did not provide assurance that there would be sufficient fuel on board flights to remote islands or isolated aerodromes. Limitations included:
    • no explicit fuel planning requirements for remote islands or isolated aerodromes
    • no formal fuel planning guidance for some relevant situations, such as a loss of pressurisation or flight below reduced vertical separation minimum (RVSM) airspace
    • no formal training for planning flights to remote islands or for international operations
    • no guidance information about potential hazards at commonly-used aerodromes
    • no procedure for a Captain’s calculation of the total fuel required to be checked by another pilot
    • little if any assessment during proficiency checks of a pilot’s ability to conduct flight/fuel planning. [Safety Issue]
  • Although passenger-carrying charter flights to Australian remote islands were required to carry alternate fuel, there were no explicit fuel planning requirements for other types of passenger-carrying flights to remote islands. There were also no explicit Australian regulatory requirements for fuel planning of flights to isolated aerodromes. In addition, Australia generally had less conservative requirements than other countries regarding when a flight could be conducted without an alternate aerodrome. [Safety Issue]
  • Although air ambulance flights involved transporting passengers, in Australia they were classified as ‘aerial work’ rather than ‘charter’. Consequently, they were subject to a lower level of regulatory requirements than other passenger-transport operations (including in terms of requirements for fuel planning of flights to remote islands). [Safety Issue]
  • The meteorological conditions were below the landing minima at the time the aircraft arrived at Norfolk Island (1003 UTC). This level of deterioration in the conditions was not indicated in the aerodrome forecast issued at 0437, prior to the departure of the flight (although an amended forecast issued at 0803 included conditions below the alternate minima).
  • Although the Nadi international flight information service officer had provided the flight crew with the 0800 UTC special weather report (SPECI) (which included conditions below the alternate minima), he did not proactively provide the flight crew with the amended aerodrome forecast for Norfolk Island issued at 0803 (which forecast conditions below the alternate minima) or the SPECI issued at 0830 (which included conditions below the landing minima).
  • After responsibility for the flight transferred to Auckland air traffic services at 0835 UTC, the Auckland air/ground operator did not confirm the flight crew had received the 0803 amended aerodrome forecast for Norfolk Island or the 0830 special weather report.
  • The flight crew did not request sufficient weather information at an appropriate time prior to reaching the point of no return (PNR) to support effective decision making. In addition, the Captain’s method for estimating the PNR to an off-track alternate aerodrome during a flight would generally not produce a specific, accurate time that could be used as an effective basis for deciding when to gather relevant weather information.
  • The Captain underestimated the risk associated with continuing the flight to Norfolk Island. This underestimation was probably associated with several contextual factors, including the limited weather information he had been provided with during the flight, the limited information he had requested during the flight, and a strong though mistaken expectancy that the automatic weather station at Norfolk Island generally overestimated the amount of cloud that was present.
  • The operator’s risk controls did not provide assurance that the operator’s Westwind pilots would conduct adequate in-flight fuel management and related activities during flights to remote islands or isolated aerodromes. Limitations included:
    • no formal guidance material about how to calculate a point of no return (PNR) for an off-track alternate aerodrome
    • no formal guidance material regarding what types of weather information to obtain during a flight and when to obtain the information
    • no procedure for a Captain’s calculation of the PNR to be checked by another pilot
    • little if any assessment during proficiency checks of a pilot’s ability to calculate a PNR and conduct in-flight fuel management on long distance flights
    • no fitment of a satellite phone in most of the operator’s Westwind aircraft. [Safety Issue]
  • The flight crew were aware that the reported weather conditions were below the alternate minima before they briefed the first approach and they were aware the reported conditions were below the landing minima before the top of descent. However, the crew did not discuss approach options, or effectively discuss contingencies if they could not successfully land off the first approach. After the first approach, the crew did not effectively review their fuel situation and consider alternate emergency options prior to ditching the aircraft.
  • The flight crew experienced significant workload, time pressure and stress during the latter stage of the flight which reduced their capacity to assess their situation, make effective decisions and conduct approaches.
  • Associated with the limited time available following the decision to ditch, the flight crew did not refer to the emergency procedures checklist for ditching and some checklist items were not completed. In particular, the Captain conducted the final approach at an airspeed significantly below the reference landing speed (Vref), which reduced the aircraft’s energy state and increased the descent rate just prior to impact.
  • The ditching was conducted in dark night conditions, which resulted in the flight crew being unable to evaluate the direction of the main swell, as well as increasing the Captain’s difficulty in conducting the flare manoeuvre.
  • The aircraft probably encountered forces during the impact sequence that were significantly greater than those the aircraft was designed to withstand. Although the survivable space within the cabin was maintained, the forces resulted in serious injuries, significant damage and rapid flooding of the aircraft.
  • Although the operator’s safety management processes were improving, its processes for identifying hazards extensively relied on hazard and incident reporting, and it did not have adequate proactive and predictive processes in place. In addition, although the operator commenced air ambulance operations in 2002, and the extent of these operations had significantly increased since 2007, the operator had not conducted a formal or structured review of its risk controls for these operations. [Safety Issue]

Other factors that increased risk:

  • The Operator and Air Ambulance provider did not have a structured process in place to conduct pre-flight risk assessments for air ambulance tasks, nor was there any regulatory requirement for such a process. [Safety Issue]
  • The aircraft’s fuel quantity gauges were probably under-reading by a total of about 260 lb during the flight. Although the flight crew were aware the fuel gauges were under-reading, the Captain became significantly concerned about the fuel situation when the indicated fuel remaining approached 0 lb.
  • Following a pilot report of under-reading fuel quantity gauges on VH-NGA on 9 October 2009, the gauges were probably not effectively calibrated.
  • The aircraft’s fuel flow gauges were probably under-reading. The flight crew of the accident flight had not identified the problem, and flight crews of previous flights had not identified and/or reported the problem.
  • The available regulatory guidance on in-flight fuel management and on seeking and applying en route weather updates was too general and increased the risk of inconsistent in-flight fuel management and decisions to divert. [Safety Issue]
  • Although the Operator provided its flight crew with basic awareness training in crew resource management (CRM), it was limited in nature and did not ensure flight crew were provided with sufficient case studies and practical experience in applying relevant CRM techniques. [Safety Issue]
  • Prior to departing Apia, the flight crew did not conduct a pre-flight safety briefing for the aircraft’s other occupants.
  • The operator’s risk controls did not provide assurance that the occupants on an air ambulance aircraft would be able to effectively respond in the event of a ditching or similar emergency. Specific examples included:
    • insufficient information provided during the pre-flight demonstrations and on the passenger safety brief card to demonstrate how to use a life jacket
    • limited procedures and guidance regarding the relative roles, responsibilities and required actions of flight crew and medical personnel during emergencies, particularly with regard to the evacuation of a patient
    • no practical training or demonstrations for medical personnel on how to use the safety equipment on board the aircraft
    • no designated location for a stretchered patient’s life jacket
    • no formal, specific procedures and limited training on how to secure life rafts in an appropriate, readily-accessible location prior to a ditching. [Safety Issue]
  • Associated with limited preparation time before the ditching and the rapid ingress of water into the cabin after the ditching, the six occupants evacuated the aircraft with only three life vests and without the aircraft’s life rafts.
  • One of the lights on the three life jackets operated for less than 85 minutes, significantly less than the 8 hours required by the relevant design standard.
  • The First Officer did not advise the Norfolk Island Unicom operator of the runway being used for the fourth approach, and her subsequent advice that they were proceeding with the ditching did not include the intended location. As a result, the rescue services initially started proceeding to an incorrect search datum, potentially delaying the recovery of any survivors.
  • Due to limited sleep in the previous 24 hours, the Captain was probably experiencing a level of fatigue that has been demonstrated to adversely influence performance.
  • The Operator’s application of its fatigue risk management system overemphasised the importance of scores obtained from a bio-mathematical model of fatigue (BMMF), and it did not have the appropriate expertise to understand the limitations and assumptions associated with the model. Overall, the operator did not have sufficient risk controls in addition to the BMMF to manage the duration and timing of duty, rest and standby periods. [Safety Issue]
  • Guidance material associated with the FAID bio-mathematical model of fatigue did not provide information about the limitations of the model when applied to roster patterns involving minimal duty time or work in the previous 7 days. [Safety Issue]
  • Although the Operator installed an enhanced ground proximity warning system (EGPWS) and traffic alert and collision avoidance system (TCAS) on VH-NGA in August 2009, it did not provide relevant flight crew with formal training on using these systems, or incorporate relevant changes into the aircraft’s emergency procedures checklists. [Safety Issue]
  • The Operator had not formally defined the roles and responsibilities of key positions involved in monitoring and managing flight operations, such as the Standards Manager for each fleet and the General Manager Flying Operations (Medivac and Charter). [Safety Issue]
  • Although the Civil Aviation Safety Authority (CASA) collected or had access to many types of information about a charter and/or aerial work operator, the information was not integrated to form a useful operations or safety profile of the operator. In addition, CASA’s processes for obtaining information on the nature and extent of an operator’s operations were limited and informal. These limitations reduced its ability to effectively prioritise surveillance activities. [Safety Issue]
  • The Civil Aviation Safety Authority’s procedures and guidance for scoping an audit included several important aspects, but it did not formally include the nature of the Operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards. [Safety Issue]

Other Findings:

  • In 2009, the amount of un-forecast weather below the landing minima at Norfolk Island was similar to that for other remote islands and also for capital city airports in Australia.
  • At the time the flight was planned, there were no weather-related or other operational requirements that affected the planning of the accident flight, or necessitated the nomination of an alternate aerodrome or the carriage of additional fuel to reach an alternate aerodrome.
  • If the aircraft manufacturer’s ‘1124A Westwind Operational Planning Manual’ was used, the aircraft departed with sufficient fuel for the flight for normal operations. If the operator’s specified fuel planning methods were used, the aircraft departed with insufficient fuel for the flight for normal operations. In either case, the flight departed with insufficient fuel to meet the regulatory requirements as there was insufficient fuel to allow for aircraft system failures.
  • At the time of the accident, many emergency locator transmitters (ELTs) were not GNSS-equipped. Such ELTs were of limited effectiveness for impacts where the ELT was unable to continue sending signals for an extended period, such as in the case of a ditching or water impact when the ELT and the associated aerial could not remain above the water for an extended period.
  • In very difficult circumstances, the doctor and flight nurse did an excellent job evacuating the patient, and then assisting the patient and injured first officer in the water. Both the doctor and nurse had undertaken helicopter underwater escape training (HUET), which they reported had helped them prepare for the evacuation.
  • The chance observation of the Captain’s torch by a fire-fighter redirected the search for the survivors to the correct location and facilitated the timely arrival of the search vessel.

Safety Recommendations

Prior to the completion of the Re-Opened Investigation, the response to all the identified Safety Issues that had been shared with the organisations at which they were directed was assessed. Almost all were classified as “adequately addressed”. However, three were not and this resulted in the issue of three Safety Recommendations as follows:

  • that the Civil Aviation Safety Authority continue its work in reviewing fuel planning requirements and guidance and address the limitations associated with requirements and guidance for fuel planning of flights for all types of passenger operations to isolated aerodromes in Australia and internationally. [AO-2014-190-SR-042]
  • that the Civil Aviation Safety Authority continue its work to address the limitations associated with the requirements and guidance for in-flight fuel management. [AO-2014-190-SR-043]
  • that the Civil Aviation Safety Authority continue reviewing the requirements for air ambulance / medical transport operations and address the limitations associated with the current classification of these flights as aerial work rather than air transport. [AO-2014-190-SR-044]

The 531-page Final Report of the Reopened Investigation was on released on 23 November 2017.

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