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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.

 

Updated: 18 February 2015

On  4 December 2014, the Australian Transport Safety Bureau (ATSB) formally re-opened investigation AO-2009-072 into the ditching of an Israeli Aircraft Industries Westwind 1124A, registered VH-NGA, which occurred 5 km south-west of Norfolk Island Airport on 18 November 2009. The action to reopen the investigation was taken by the ATSB Commission in response to the recently-released peer review, by the Transportation Safety Board (TSB) of Canada, of the ATSB’s investigation methodologies and their general application including in investigation AO-2009-072. The TSB review highlighted how ATSB methodologies could have been better applied in investigation AO-2009-072 to meet the expectations of the aviation industry and the public.

The re-opened investigation will review the evidence obtained during the original ATSB investigation, and the report of that investigation, in the light of any additional evidence and other relevant points raised in the TSB review and separate reviews by the Senate Rural and Regional Affairs and Transport References Committee and through the Deputy Prime Minister’s Aviation Safety Regulation Review. The main focus will be ensuring that the specific findings of the TSB review are taken fully into account before issuing a final report of the re-opened investigation.

The re-opened investigation will in particular be examining:

  • pre-flight planning and fuel management procedures and practices
  • in-flight fuel management and related decision-making procedures and practices
  • fatigue management procedures and practices
  • flight crew check and training
  • the operator’s oversight of its flight operations activities
  • provision of weather and other flight information to flight crews
  • cabin safety and survival factors
  • regulatory oversight of activities such as those listed above.

The re-opened investigation has already requested a substantial amount of additional documentation from the operator, the Civil Aviation Safety Authority (CASA) and other parties. After reviewing the existing evidence and additional documentation, the investigation team will also be seeking to interview a number of personnel from the operator, CASA and other organisations, as well as re-interviewing occupants of the accident aircraft. In addition, the ATSB will take all reasonable steps to recover the flight recorders from the accident aircraft and download and analyse the data from them.

The re-opened investigation is being conducted by an experienced team of ATSB investigators who have expertise in flight operations, human factors, organisational factors, air traffic control and cabin safety, and who were not part of the original investigation team. Oversight of the investigation team and lines of reporting to the ATSB Commissioners for the re-opened investigation have also been changed from the original investigation.

The draft report from the re-opened investigation will be sent to Directly Involved Parties for feedback before being publicly released, in line with the ATSB’s normal processes.

The re-opened investigation is in its early stages. Given the level of work involved, it is expected to take 8 to 12 months to complete. In parallel, the previously issued final report of the investigation has been removed from the ATSB website until the re-opened investigation is complete. If any new safety issues are identified during the investigation, these will be communicated to the relevant parties as soon as possible.

 
Download Preliminary Report
[PDF: 1.07MB]
 
 
 

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.

Download Preliminary Report
[PDF: 1.07MB]
 
 
 
 

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:
Status:Adequately addressed


 

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:
Status:Adequately addressed

 

General details

Date: 18 Nov 2009 Investigation status: Active 
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: 18 Feb 2015 Occurrence category: Accident 
Report status: Pending Highest injury level: Serious 
Expected completion: Dec 2015  
 

Aircraft details

Aircraft manufacturer: Israel Aircraft Industries Ltd 
Aircraft model: Westwind 1124A 
Aircraft registration: VH-NGA 
Serial number: 387 
Type of operation: Aerial Work 
Sector: Jet 
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 18 February 2015