2009 Pel-Air Westwind ditching

Aviation accident near Norfolk Island October 2017 October 2017 2009 Pel-Air Westwind ditching Pel-Air (VH-KNR) IAI 1124A Westwind parked at Sydney Airport.jpg A Pel-Air Westwind II, sister aircraft to that involved in the accident 18 November 2009 Ditching following pilot error and ATC error Accident Norfolk Island -29.075 167.95 type:event title,inline 4 2 0 6 6 IAI 1124A Westwind II Apia, Samoa Norfolk Island Melbourne Pel-Air VICTOR HOTEL NOVEMBER GOLF ALPHA VH-NGA The 2009 Pel-Air Westwind ditching or Norfolk Island ditching was an aircraft accident on 18 November 2009 near Norfolk Island, Australia. A Westwind II jet operated by Pel-Air was conducting an air ambulance flight for CareFlight when it was forced to ditch after being unable to land in bad weather and not having sufficient fuel to divert to an alternate destination. The official accident report issued 2 1 2 years later by the Australian Transport Safety Bureau (ATSB) attracted wide criticism, and resulted in an parliamentary inquiry that found both the ATSB and the Civil Aviation Safety Authority (CASA) had failed to carry out their responsibilities with respect to the accident investigation. In response to the criticism, the ATSB requested that the Transportation Safety Board of Canada review the ATSB's investigation methodologies and processes,http://www.bst-tsb.gc.ca/eng/coll/2014/ATSB/revue-review-20141201.asp Independent review of the Australian Transport Safety Bureau's investigation methodologies and processes Transportation Safety Board of Canada 1 December 2014 and subsequently reopened the investigation on 8 December 2014.https://www.atsb.gov.au/newsroom/2014/atsb-begins-action-on-canadian-review.aspx ATSB begins action on Canadian review Australian Transport Safety Bureau 8 December 2014 The final report of the reopened investigation was released on 23 November 2017, and contained 531 pages and 36 safety factors. Flight details On 18 November 2009, an IAI 1124A Westwind II conducted an air ambulance flight from Apia, Samoa to Melbourne on behalf of CareFlight. The aircraft was scheduled to land at Norfolk Island to refuel, but weather conditions deteriorated while it was en route. The aircraft did not carry enough fuel to divert to an alternate destination. After not being able to make visual observation of the runway after four instrument approaches,http://www.atsb.gov.au/media/1345477/ao-2009-072-prelim.pdf Ditching – Norfolk Island – 18 November 2009 Australian Transport Safety Bureau 13 January 2010 7 March 2010 https://web.archive.org/web/20100324092617/http://www.atsb.gov.au/publications/investigation_reports/2009/aair/ao-2009-072.aspx 24 March 2010 live the crew ditched the aircraft in open sea 6 km nmi west of Norfolk Island in darkness and bad weather. A pocket torch that the captain had in his possession and used as a distress signal was spotted from land in an area of the sea where the search and rescue effort was initially not concentrated; all six occupants were rescued by local fishermen after 90 minutes in the water.Australian Transport Safety Bureau Aviation Safety Investigation Report – IAI 1124A VH-NGA. Retrieved 4 April 2017.http://www.rex.com.au/MediaAndPressClippings/ShowNews.aspx?site=IR&nid=224 CareFlight/Pel-Air Medical Evacuation Incident – Samoa to Melbourne Regional Express Holdings 20 November 2009 19 November 2009 Investigation The accident report by the Australian Transport Safety Bureau (ATSB) states "At Apia, the pilot in command submitted a flight plan by telephone to Airservices Australia. At that time, the forecast weather conditions at Norfolk Island for the arrival did not require the carriage of additional fuel for holding, or the nomination of an alternate airport". The ATSB report further states that the main tanks of the aircraft were full "which would provide sufficient fuel and reserves for the flight".Veness 2010 The press reported that the pilot was suspended pending the outcome of the official investigation.Robinson 2010 The Civil Aviation Safety Authority (CASA) investigated the flight planning, fuel planning and management, and decision-making that contributed towards the accident.Robinson 2010 Senate inquiry and controversy On 23 May 2013, a report was released by the Australian Senate following an inquiry into the ATSB investigation of the ditching.Rural and Regional Affairs and Transport References Committee 2013 59 This inquiry was sparked by a Four Corners documentary that aired allegations of misconduct by the ATSB and CASA.Thompson Masters 2012 The Senate's report found that the ATSB accident report was deeply flawed and unfairly blamed the pilot wholly for the accident, and as a consequence the Senate recommended that the accident report be withdrawn and re-done. "It is disappointing that CASA and the ATSB continue to assert, in the face of evidence to the contrary, that the only part of the system with any effect on the accident sequence was the pilot.." Rural and Regional Affairs and Transport References CommitteeRural and Regional Affairs and Transport References Committee 2013 xxi The Senate committee determined that the ATSB's decision not to retrieve the flight recorders was incongruous with its responsibilities under International Civil Aviation Organization (ICAO) Chicago Convention Annex 13.Rural and Regional Affairs and Transport References Committee 2013 29–30 It also found evidence of collusion between the agencies; that CASA deliberately withheld the Chambers Report from the ATSB; and that the heads of both agencies gave testimony that wasn't credible. The committee made a total of 26 recommendations covering the accident, the operations of the ATSB and the operations of CASA. The committee also passed evidence to the Australian Federal Police, pending the possibility of charges being laid against individuals from CASA who were involved in breaching the Transport Safety Investigation Act 2003.Rural and Regional Affairs and Transport References Committee 2013 Subsequent actions In response to the criticism, the ATSB requested the Transportation Safety Board of Canada (TSB) to review the Australian investigation methodologies and processes. The TSB review concluded that the ATSB's methodologies and processes met or exceeded the recommended practices described in ICAO Annex 13, but its application to the accident at Norfolk Island fell short of the ATSB's own standards. On 8 December 2014, the ATSB reopened the investigation. On 11 November 2015 the flight recorders were retrieved from the wreckage on the seabed. Both flight recorders contained valid data. The final report of the reopened investigation was released on 23 November 2017. In the 531-page final report, most of the responsibility was still placed on the pilot for inadequate fuel planning and weather checking.https://www.theaustralian.com.au/news/pelair-pilot-who-ditched-plane-in-sea-acted-within-lax-guidelines/news-story/69046fb2d0cd23e0283105c366476089 Pel-Air pilot who ditched plane in sea acted 'within lax guidelines' Ean Higgins The Australian 23 November 2017 However, the report also acknowledged that the pilot was operating within company rules and regulatory guidance, both of which were lax. In particular, air ambulance flights were classified as "aerial work" rather than "charter", resulting in such flights being subjected to looser requirements than other passenger-carrying flights. It also commented that air traffic controllers at Nadi and Auckland failed to inform the pilot of the deteriorating weather conditions at Norfolk Island before the flight reached the point of no return, although the pilot also did not proactively request such information. Footnotes References http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Rural_and_Regional_Affairs_and_Transport/Completed_inquiries/2012-13/pelair2012/report/index Aviation accident investigations May 2013 Rural and Regional Affairs and Transport References Committee Government of Australia https://www.theaustralian.com.au/business/aviation/safety-regulators-lashed-over-air-crash-failings/news-story/2fc95624aaed83f5b59b80260e0d07ad Safety regulators lashed over air crash failings 24 May 2013 Steve Creedy subscription The Australian http://www.smh.com.au/opinion/political-news/air-safety-body-slammed-over-air-ambulance-crash-investigation-20130523-2k2m1.html Air safety body slammed over air ambulance crash investigation Matt O'Sullivan Sydney Morning Herald 23 May 2013 http://www.smh.com.au/national/glamour-pilot-no-hero-passengers-20100308-ps6d.html Glamour Pilot No Hero: Passengers Sydney Morning Herald 8 March 2010 9 March 2010 Georgina Robinson https://web.archive.org/web/20100310043821/http://www.smh.com.au/national/glamour-pilot-no-hero-passengers-20100308-ps6d.html 10 March 2010 live http://blogs.crikey.com.au/planetalking/2013/05/23/casa-referred-to-federal-police-by-senate-committee/ CASA referred to Federal Police by Senate committee Ben Sandilands 23 May 2013 Crikey 24 May 2013 8 July 2013 https://web.archive.org/web/20130708095620/http://blogs.crikey.com.au/planetalking/2013/05/23/casa-referred-to-federal-police-by-senate-committee dead http://www.abc.net.au/4corners/stories/2012/08/30/3579404.htm Crash Landing Geoff Thompson Deb Masters ABC 5 September 2012 http://news.smh.com.au/breaking-news-national/crashed-plane-had-to-ditch-report-20100113-m6d2.html Crashed plane had to ditch Peter Veness 13 January 2010 7 March 2010 Sydney Morning Herald http://www.abc.net.au/news/2013-05-23/senate-committee-raises-concerns-about-authorities-overseeing-a/4709104 Senate Committee releases damning report into Australia's aviation authorities Naomi Woodley 23 May 2013 ABC External links CASA Media Release – Monday 23 November 2009 Video at Australian Transport Safety Bureau L2DkLXuyzoA Category:Aviation accidents and incidents in 2009 2009 Pel-Air Westwind ditching Category:2009 in Australia 2009 Pel-Air Westwind ditching Category:Aviation accidents and incidents caused by fuel exhaustion Category:Public inquiries in Australia Category:November 2009 in Australia Category:21st century in Norfolk Island Category:Airliner accidents and incidents involving ditching Category:2009 disasters in Australia Category:Aviation accidents and incidents involving the IAI Westwind