The Australian Transport Safety Bureau (ATSB) has today released its final report into the reopened investigation of the 18 November 2009 accident involving Israel Aircraft Industries Westwind 1124A aircraft, VH-NGA, near Norfolk Island.

The flight, which was conducting an air ambulance flight, took off from Apia, Samoa, bound for Australia, via Norfolk Island for a fuel stop. On arrival at Norfolk Island, low cloud prevented the crew from making a safe landing. After four unsuccessful approaches, and with insufficient fuel to divert to another airport, the aircraft was ditched into waters 6.4 km west-south-west of the airport. All six occupants evacuated from the aircraft and were rescued by boat.

The ATSB formally reopened its investigation on 4 December 2014 following criticism of its original investigation by the aviation industry and was subject to an inquiry by the Australian Senate’s Rural and Regional Affairs and Transport References Committee.

Prior to commencing the reopened investigation, the ATSB requested the Transportation Safety Board of Canada (TSB) conduct an independent peer review of its investigation methodologies and processes. Its review, which included an examination of two previous aviation investigations along with the original investigation involving VH-NGA, stated that “The TSB Review compared the two organisations’ methodologies against the standards and recommended practices outlined in Annex 13 to the International Civil Aviation Organization (ICAO) Convention on International Civil Aviation, and found they met or exceeded the intent and spirit of those prescribed.”

However, the review also found deficiencies in how the ATSB’s methodologies were applied in the case of the Norfolk Island investigation and identified 14 recommendations for the ATSB to enhance the quality and the way in which it conducts future safety investigations.

Special measures were taken to ensure the reopened investigation remained distinct from the original and to avoid the possibility of any preconceptions or conflicts of interest. As part of those measures, it was conducted by investigators and overseen by managers who had not been involved in the original investigation. Additionally, the ATSB’s current Chief Commissioner, Greg Hood, was not involved in any part of the investigation, as he had been in a senior role at the aviation regulator, the Civil Aviation Safety Authority (CASA), at the time of the accident.

The new investigation team reviewed evidence obtained during the original investigation and acquired a substantial amount of additional information that was not obtained or available to the original investigation team. This new material included data from the aircraft’s recovered flight recorders and over 30 additional interviews with a range of people, including a number of other Westwind pilots from the operator, inspectors from CASA, as well as re-interviewing the flight crew and medical crew who were on board the aircraft.

The Commission review and approval process of the final investigation report was led by the ATSB’s aviation-experienced Commissioner, Chris Manning.

“This investigation report is one of the largest and most thorough safety investigations the ATSB has completed,” said Commissioner Manning. “The ATSB obtained sufficient evidence to establish findings across a number of lines of enquiry, including relating to individual actions, local contextual factors, the operator’s risk controls and regulatory matters.

The significantly large volume of additional evidence and the complex nature of the analysis of a number of the issues meant that the reopened investigation took longer than originally foreseen.

“The ATSB recognises the importance of being able to demonstrate that the reopened investigation addressed identified areas for improvement with the original investigation.” said Commissioner Manning. “A main focus of the reopened investigation was to address all of the relevant points raised by the Senate inquiry. We have also ensured the specific findings of the TSB’s review were fully taken into account in our final report.”

Commissioner Manning added the thoroughness and level of detail in the final report was substantially more than would normally be the case for a safety investigation of this nature. The final report found 36 safety factors, including 16 safety issues. This large number of safety issues and factors was due in part to the amount of information obtained by the reopened investigation and the depth to which it was analysed.

“The ATSB adopted this approach to address a wide range of matters raised by various parties regarding the original investigation report,” said Commissioner Manning. “The ATSB was mindful at all times that the people and organisations involved in this accident have been intently waiting for the results of the reopened investigation and acknowledges the time that it has taken to complete the final report.”

Commissioner Manning said the most fundamental lesson from this reopened investigation for the regulator, operators and flight crews is to recognise that unforecast weather can occur at any aerodrome and can be especially challenging at remote islands and isolated locations.

“Consequently, there is a need for robust and conservative fuel policies, planning and in-flight management procedures for passenger-carrying transport flights to these types of destinations” said Commissioner Manning.

The final investigation report, AO-2009-072 (reopened), ‘Fuel planning event, weather-related event and ditching involving Israel Aircraft Westwind 1124A aircraft, VH-NGA, 6.4 km WSW of Norfolk Island Airport on 18 November 2009’, has been published on the ATSB’s website.

Editor’s note: Broadcast video and audio grabs of Commissioner Manning are available to media outlets on request by emailing: media@atsb.gov.au

Last update 23 November 2017

Final Report

Fuel planning event, weather-related event and ditching involving Israel Aircraft Industries Westwind 1124A, VH-NGA, 6.4 km WSW of Norfolk Island Airport, on 18 November 2009