The Australian Transport Safety Bureau (ATSB) has today released the much-awaited second investigation report into the Norfolk Island ditching in 2009, with the findings having impact on the flight crew, the operator and the Civil Aviation Safety Authority across a number of areas.
Pel-Air Westwind VH-NGA was on an aeromedical transfer flight from Samoa to Melbourne on 18 November 2009, when it was forced to ditch off Norfolk Island after poor weather and four failed attempts to land left it without enough fuel to divert to an alternate airport.
The first investigation report indicated failings on behalf of the flight crew's planning and weather monitoring, which caused controversy and a senate inquiry. After a rebuke during a Canadian Transportation Safety Board review in December 2014, and under pressure from then Minister for Infrastructure and Transport Warren Truss, the ATSB agreed to re-open the investigation.
The 531-page investigation report released today contains the following findings.
- The flight departed Apia, Samoa, without taking on the maximum amount of fuel possible, which the ATSB says was contrary to the operator's consistent practice.
- Pre-flight planning did not include elements to reduce the risk of flying to a remote island or isolated aerodrome.
- Pel-Air's risk controls did not provide for assurance that there would be sufficient fuel on board flights to remote islands or isolated aerodromes.
- Although passenger charter flights to remote island are required to carry fuel for alternates, there are no specific requirements for other types of passenger-carrying flights, such as aeromedical, which is classified as aerial work.
- The weather at Norfolk Island was below the landing minima when the flight arrived, and that those conditions were not in the TAF issued before the flight left Samoa.
- Although international flight service did supply VH-NGA with a SPECI that noted the reduced weather at Norfolk Island, they did not pro-actively provide the amended TAF.
- After the flight was handed off to Auckland, the Auckland controller did not confirm if the flight had the amended TAF.
- The flight crew did not request updated weather at an appropriate time prior to reaching the Point-of-No-Return (PNR).
- The captain underestimated the risk of continuing to Norfolk Island, most probably because of the limited weather information provided.
- At top of descent the crew was aware of the conditions at Norfolk, but did not brief what actions they would take if the first approach was not successful. Also the crew did not review the fuel after the first failed approach and consider other options.
- Significant workload, time pressure and stress hampered the flight crew's capacity to assess the situation and make effective decisions.
- The crew did not refer to the ditching checklist and some items weren't completed, most significantly the speed on final was below the reference speed, which increased the descent rate just prior to impact.
- Because the ditching happened at night, the captain couldn't evaluate the direction of the main ocean swell and increased the difficulty in flaring the aircraft.
- Impact forces were greater than those the aircraft was designed to withstand.
- Pel-Air did not have pro-active and predictive processes for identifying hazards.
The ATSB also found several factors that increased the risk, including:
- Pel-Air didn't have a structured process in place for conducting pre-flight risk assessments, and that CASA didn't require it
- CASA had limited ability to effectively conduct surveillance on Pel-Air because, although CASA had plenty of information about operators of aerial work and charter, the information was not integrated, so couldn't form a useful operations or safety profile of the company
- CASA's procedures for conducting an audit did not formally include the nature of the operations, inherent threats or hazards, or the operator's controls for managing the threats and hazards
- CASA's approach to surveillance had placed significant emphasis on system-based audits, and that this approach resulted in minimal emphasis on the actual line operations.
The investigation report also contains several safety issues and notes that Pel-Air and CASA have already adequately addressed a significant number of those issues.
The full report is on the ATSB website.