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What happened

On 18 November 2009, the flight crew of an Israel Aircraft Industries Westwind 1124A aircraft, registered VH-NGA, was attempting a night approach and landing at Norfolk Island on an aeromedical flight from Apia, Samoa. On board were the pilot in command and copilot, and a doctor, nurse, patient and one passenger.

On arrival, weather conditions prevented the crew from seeing the runway or its visual aids and therefore from landing. The pilot in command elected to ditch the aircraft in the sea before the aircraft's fuel was exhausted. The aircraft broke in two after ditching. All the occupants escaped from the aircraft and were rescued by boat.

What the ATSB found

The requirement to ditch resulted from incomplete pre-flight and en route planning and the flight crew not assessing before it was too late to divert that a safe landing could not be assured. The crew's assessment of their fuel situation, the worsening weather at Norfolk Island and the achievability of alternate destinations led to their decision to continue, rather than divert to a suitable alternate.

The operator's procedures and flight planning guidance managed risk consistent with regulatory provisions but did not minimise the risks associated with aeromedical operations to remote islands. In addition, clearer guidance on the in-flight management of previously unforecast, but deteriorating, destination weather might have assisted the crew to consider and plan their diversion options earlier.

The occupants' exit from the immersed aircraft was facilitated by their prior wet drill and helicopter underwater escape training. Their subsequent rescue was made difficult by lack of information about the ditching location and there was a substantial risk that it might not have had a positive outcome.

What has been done to fix it

As a result of this accident, the aircraft operator changed its guidance in respect of the in-flight management of previously unforecast, deteriorating destination weather. Satellite communication has been provided to crews to allow more reliable remote communications, and its flight crew oversight systems and procedures have been enhanced. In addition, the Civil Aviation Safety Authority is developing a number of Civil Aviation Safety Regulations covering fuel planning and in‑flight management, the selection of alternates and extended diversion time operations.

Safety message

This accident reinforces the need for thorough pre- and en route flight planning, particularly in the case of flights to remote airfields. In addition, the investigation confirmed the benefit of clear in-flight weather decision making guidance and its timely application by pilots in command.

 

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NOTICE:  On 31 August 2012 a clarification was added on page 6, para 3. The report  did not originally make it clear that air traffic control communicated an incorrect cloud height.

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Preliminary report released 13 January 2010

On 18 November 2009, an Israel Aircraft Industries Westwind 1124A aircraft, registered VH-NGA, ditched in the ocean 3 NM (6 km) to the west of Norfolk Island. The six occupants evacuated the sinking aircraft and were later recovered by a rescue vessel from Norfolk Island.

The flight crew had been unable to conduct a landing at Norfolk Island Airport because they could not see the runway after conducting four instrument approaches. The crew then elected to ditch before the aircraft's fuel supply was exhausted.

Following the event, the aircraft operator initiated a program of checking and revalidation for the company's commercial Westwind pilots.

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Wreckage of the aircraft off Norfolk Island

 

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Safety issues

AO-2009-072-SI-01 - AO-2009-072-SI-02 -  

Fuel planning and en route decision-making

The available guidance on fuel planning and on seeking and applying en route weather updates was too general and increased the risk of inconsistent in-flight fuel management and decisions to divert.

Issue Number:AO-2009-072-SI-01
Who it affects:All operations


 

Oversight of the flight and its planning

The operator’s procedures and flight planning guidance managed risk consistent with regulatory provisions but did not effectively minimise the risks associated with aeromedical operations to remote islands.

Issue Number:AO-2009-072-SI-02
Who it affects:The operator

 

General details

Date: 18 Nov 2009 Investigation status: Completed 
Time: 1026 UTC Investigation type: Occurrence Investigation 
Location   (show map):5 km SW of Norfolk Island Airport Occurrence type:Aircraft preparation 
State: External Territory Occurrence class: Operational 
Release date: 30 Aug 2012 Occurrence category: Accident 
Report status: Final Highest injury level: Serious 
 

Aircraft details

Aircraft manufacturer: Israel Aircraft Industries Ltd 
Aircraft model: 1124 
Aircraft registration: VH-NGA 
Serial number: 387 
Type of operation: Aerial Work 
Damage to aircraft: Serious 
Departure point:Apia, Samoa
Departure time:0545 UTC
Destination:Norfolk Island

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Released under s25 of the Transport Safety Investigation Act 2003
 
 
 
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Last update 25 March 2014