2009 Pel-Air Westwind ditching
A Pel-Air Westwind II, sister aircraft to that involved in the accident
|Date||18 November 2009|
|Aircraft type||IAI 1124A Westwind II|
|Flight origin||Apia, Samoa|
The 2009 Pel-Air Westwind ditching, Norfolk Island ditching or CareFlight 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 International 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 two and half years later by the Australian Transport Safety Bureau (ATSB) attracted wide criticism, and resulted in an Australian Senate Enquiry 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, and subsequently reopened the investigation on 8 December 2014.
On 18 November 2009, an IAI 1124A Westwind II conducted an air ambulance flight from Apia, Samoa to Melbourne, Australia 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, the crew ditched the aircraft in open sea 6 kilometres (3.2 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.
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". The press reported that the pilot was suspended pending the outcome of the official investigation. The Civil Aviation Safety Authority (CASA) investigated the flight planning, fuel planning and management, and decision-making that contributed towards the accident.
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. This inquiry was sparked by a Four Corners documentary that aired allegations of misconduct by the ATSB and CASA. 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 Committee
The Senate committee determined that the ATSB's decision not to retrieve the flight recorders was incongruous with its responsibilities under International Civil Aviation Organisation (ICAO) Chicago Convention Annex 13. 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, as well as the operations of the ATSB and 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.
In response to the criticism, the ATSB requested a review of its investigation methodologies and processes by the Transportation Safety Board of Canada (TSB). 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; and retrieved the flight recorders on 11 November 2015. Both flight recorders contained valid data. The final report of the reopened investigation is expected in the first quarter of 2016.
- "Independent review of the Australian Transport Safety Bureau's investigation methodologies and processes". Transportation Safety Board of Canada. 2014-12-01.
- "ATSB begins action on Canadian review". Australian Transport Safety Bureau. 2014-12-08.
- "Ditching – Norfolk Island – 18 November 2009" (PDF). Australian Transport Safety Bureau. 2010-01-13. Archived from the original on 24 March 2010. Retrieved 2010-03-07.
- Australian Transport Safety Bureau Aviation Safety Investigation Report - IAI 1124A VH-NGA retrieved 4 December 2009.
- "CareFlight/Pel-Air Medical Evacuation Incident - Samoa to Melbourne" (Press release). Regional Express Holdings. 2009-11-19. Retrieved 2009-11-20.
- Veness 2010.
- Robinson 2010.
- Rural and Regional Affairs and Transport References Committee 2013, p. 59.
- Thompson & Masters 2012.
- Rural and Regional Affairs and Transport References Committee 2013, p. xxi.
- Rural and Regional Affairs and Transport References Committee 2013, pp. 29-30.
- Sandilands 2013.
- Rural and Regional Affairs and Transport References Committee 2013.
- Rural and Regional Affairs and Transport References Committee (May 2013). "Aviation accident investigations". Government of Australia.
- Creedy, Steve (May 24, 2013). "Safety regulators lashed over air crash failings". The Australian.
- O'Sullivan, Matt (May 23, 2013). "Air safety body slammed over air ambulance crash investigation". The Sydney Morning Herald.
- Robinson, Georgina (2010-03-08). "Glamour Pilot No Hero: Passengers". Sydney Morning Herald. Archived from the original on 10 March 2010. Retrieved 2010-03-09.
- Sandilands, Ben (May 23, 2013). "CASA referred to Federal Police by Senate committee". Crikey.
- Thompson, Geoff; Masters, Deb (September 5, 2012). "Crash Landing". ABC.
- Veness, Peter (2010-01-13). "Crashed plane had to ditch". Sydney Morning Herald. Retrieved 2010-03-07.
- Woodley, Naomi (May 23, 2013). "Senate Committee releases damning report into Australia's aviation authorities". ABC.