Aviation safety investigations & reports

Piper Aircraft Corp PA-31 , VH-TWR

Investigation number:
Status: Completed
Investigation completed


A Piper Chieftain was undertaking a regular public transport (RPT) flight from Lord Howe Island to Norfolk Island. The flight had been originally scheduled for Sunday 14 February but was cancelled due to adverse weather conditions at Norfolk Island. On the morning of 15 February, the terminal area forecast (TAF) for Norfolk Island required the carriage of fuel to an alternate aerodrome. As the aircraft was unable to carry sufficient fuel for the flight to Norfolk Island and then to an alternate, the flight was again postponed.

At about midday on the same day, the pilot found that a revised TAF now only required the carriage of an additional 60 minutes of holding fuel for arrival at Norfolk Island. The forecast, issued at 1133, indicated that from 1200 to 2300 there would be broken (more than 4/8ths) cloud at 2,500 ft, scattered (4/8ths or less) cloud at 500 ft, and visibility reduced to 8,000 m in rain showers. In addition, there would be periods of up to 60 minutes (TEMPO) of broken cloud at 400 ft, with visibility reduced to 4,000 m in drizzle. The minima for a straight-in landing approach to runway 11 required not more than 4/8ths cloud below 750 ft, with a visibility of not less than 2,700 m. The alternate minima required not more than 4/8ths cloud below 1,069 ft, and visibility not less than 4,400 m.

The aircraft subsequently departed Lord Howe Island carrying the additional holding fuel. Before reaching his calculated point of no return (PNR) at about 1545 the pilot received two meteorological reports (METARs) of conditions at Norfolk Island. Both reports described conditions below the published alternate and landing minima. Moreover, an amended TAF for Norfolk Island issued at 1420 indicated that from 1400 to 2300 the amount of cloud at 500 ft had increased to broken (more than 4/8ths). Based on that amendment the pilot was required to nominate an alternate aerodrome for the flight. However, he did not request or receive the amended weather forecast before passing the PNR, as required by the company operations manual.

As the flight approached Norfolk Island, the pilot was advised of reducing visibility. He conducted an instrument approach to runway 11 but did not become visual, and so carried out a missed approach. In conditions of deteriorating visibility the pilot then flew several approaches to runway 04 by descending over the sea until he was visual, at a height of approximately 500 ft, before tracking inbound on the instrument approach VOR (a navigation aid) radial. On the first two approaches, the pilot was unable to see the aerodrome and conducted a missed approach.

For the third approach, the pilot requested the aerodrome manager to position himself on the runway threshold in order to indicate by radio the position of the aircraft in relation to the runway centreline. The manager did this and advised the pilot that the aircraft had passed to the right of the centreline. On the fourth approach, the pilot sighted the precision approach path indicator lights and landed on the runway. Visibility at the time of landing was recorded as 800 m in fog.

The pilot later reported that he had made the decision to continue beyond the PNR, based on the forecast obtained at the time he had completed his flight planning. He believed that it was still the current forecast as he had not been advised during the flight of any amendments to that forecast.

Several factors were considered significant to the development of this occurrence. The meteorological conditions which developed at Norfolk Island later in the day, were considerably worse than those forecast by the TAFs issued at 1133 and 1420. Both forecasts indicated that conditions would be below the landing minima for periods of up to 60 minutes. In reality, the conditions at Norfolk Island were below the landing minima continuously from 1130 until after 2330. Had the pilot requested the latest TAF before passing the PNR, he would have been obliged to return to Lord Howe Island, the nearest alternate. In addition, the pilot did not use or did not acknowledge the significance of the METAR information he had received in flight to challenge the accuracy of the TAF that he used for his decision making.

As the regulations did not require RPT aircraft conducting flights to Norfolk Island to carry sufficient fuel for flight to an alternate aerodrome, the pilot carried only an additional 60 minutes of fuel in accordance with the operational requirements of the 1133 TAF. Having passed his PNR, the aircraft did not have sufficient fuel to return to Lord Howe Island, and the pilot was subsequently left with limited options when he encountered the subsequent conditions at Norfolk Island.

Safety Action

Local safety action by the regulator

As a result of this and similar occurrences, the Civil Aviation Safety Authority amended the Civil Aviation Orders, effective from 16 August 1999. Under the amended orders, all charter passenger-carrying flights to Norfolk Island and other remote islands, must carry fuel for flight to the destination, then to an alternate aerodrome. The alternate aerodrome must not be located on a remote island. Fuel requirements related to RPT operations to remote islands have not been affected by that amendment.

BASI safety action

As a result of this and similar occurrences, the Bureau of Air Safety Investigation is currently investigating a number of safety deficiencies. The safety deficiencies identified relate to the accuracy of meteorological forecasts for Norfolk Island and the regulations covering RPT flights to remote island destinations. Any safety output as a result of this analysis will be published in the Bureau's Quarterly Summary of Safety Deficiency.

General details
Date: 15 February 1999   Investigation status: Completed  
Time: 1749 hours ESuT    
Location   (show map): Norfolk Island, Aero.    
State: New South Wales    
Release date: 13 December 1999   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-31  
Aircraft registration VH-TWR  
Type of operation Air Transport Low Capacity  
Damage to aircraft Nil  
Departure point Lord Howe Island, NSW  
Departure time 1355 hours ESuT  
Destination Norfolk Island  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command ATPL 500.0 7000
Last update 13 May 2014