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Updated: 25 May 2015

The previous update on 24 April 2015 outlined the results of a recent underwater survey of the aircraft’s wreckage. Based on this survey, the ATSB is currently assessing options for the task of recovering the recorders.

Other investigation activities to date have included:

  • Reviewing documentation from the original ATSB investigation and the Senate Inquiry conducted by the Senate Rural and Regional Affairs and Transport References Committee in 2012-2013.
  • Reviewing documentation from investigations into the accident conducted by the Civil Aviation Safety Authority (CASA) and the operator.
  • Reviewing documentation from the operator, including flight records for several Westwind aircraft, check and training records for several flight crew, duty times and rosters, occurrence and hazard reports, audit reports, and safety committee meeting records.  
  • Interviewing 14 personnel from the operator, including management, check and training pilots and line pilots.
  • Comparing the operator’s policies and procedures and other requirements with its operational practices, particularly in areas such as flight planning, fuel management, fatigue management, and emergency procedures.
  • Comparing the results from three bio-mathematical models of fatigue when applied to a series of the operator’s duty periods, and examining the suitability of the FAID model and related guidance material when applied to the operator’s air ambulance operations.
  • Reviewing documentation from the air traffic services’ providers in Fiji and New Zealand about their policies and procedures for the provision of flight information, and how these were applied during the accident flight.
  • Reviewing CASA’s surveillance files and related documentation for the operator.
  • Reviewing documentation and interviewing personnel from the air ambulance contracting company.

During the Senate Inquiry associated with the original ATSB investigation, significant concerns were raised by some of the aircraft’s occupants about the serviceability and design of the life jackets used by three of the occupants. The re-opened investigation established that the life jackets had been retained by the Norfolk Island Police Force since the accident. The ATSB has now taken possession of the life jackets, and they will be examined after consultation with relevant parties. The life jackets were required to be serviced every 5 years, and all three jackets had been serviced within the 5-year period prior to the accident.

As well as continuing with the above activities, the next phase of the investigation will involve:

  • Interviewing several personnel from CASA.
  • Comparing the operator’s policies, procedures and practices with other air ambulance operators.
  • Examining the reliability of weather forecasting at Norfolk Island.

________

The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.

 

 

Updated: 24 April 2015

On 4 December 2014, the ATSB formally reopened the investigation into the ditching of an Israeli Aircraft Industries Westwind 1124A aircraft, registered VH-NGA. As part of the re-opened investigation the ATSB is taking all reasonable steps to recover the flight recorders from the accident aircraft and download and analyse the data from them.

In order to make an informed assessment of the feasibility of recovering the recorders from the tail of the aircraft, the ATSB recently conducted an underwater survey of the aircraft wreckage on 28–29 March 2015. The survey was completed with the assistance of specialist dive officers from New South Wales Police and the Australian Federal Police. A remotely operated vehicle (ROV) equipped with video recording capability was used in the conduct of the survey. The images were compared with those undertaken for the ATSB in the initial ROV survey, conducted in December 2009.

Conditions for the latest survey were difficult, with large ocean swells, poor visibility and a strong underwater current, all likely as a result of the passage of Cyclone Pam to the north of Norfolk Island a couple of weeks previously. Regardless of the less than ideal conditions, the survey exercise was successful and adequate for the ATSB to continue its planning for the next phase based on a good understanding of the state of the wreckage:

  • The wreckage remains at its last recorded position, submerged in water to a depth of 48 m, approximately 4.5 km to the west of Norfolk Island.
  • Both wings, both engines, the rear section of fuselage and the tail remain attached and were accounted for during the survey.
  • The two major fuselage segments are no longer connected by flight control cables (as they were in 2009) and the front section of the passenger compartment has shifted slightly as a result of underwater currents, but the two segments remain close together.
  • The wreckage has been resting on a sandy-based ocean floor and as a consequence the tail section of the fuselage containing the flight recorders has been partially buried by the movement of sand. The left and right main landing gear have also been partially buried by sand.
  • Both engines, as well as the left and right wings, remain clear of the sandy ocean floor. 

 

Sample images are provided in Figures 1-3.

Figure 1: March 2015 ROV still image of aircraft wreckage view looking downAircraft wreckage view looking down
Source: ATSB

 

Figure 2: March 2015 ROV still image from the right side of the aircraft view looking rearwardAircraft wreckage left side of the aircraft tail
Source: ATSB

 

Figure 3: March 2015 ROV still image from the left side of the aircraft tail: the rear fuselage section containing the flight recorders is partially buried in sand
Aircraft wreckage - right side of the aircraft view looking rearward
Source: ATSB

Based on enquiries by the ATSB, it does not appear that there have been any successful dives onto the actual wreckage by independent parties since the accident. The depth of the water at the site requires the use of specialised commercial diving expertise and equipment, including the provision of a hyperbaric chamber in case of an emergency situation. In addition there are no locally available vessels capable of lifting the aircraft from the ocean floor. The information obtained from this latest underwater survey will be used to assist the ATSB in its planning and assessment of options for the next phase of the project to recover the recorders.

The main focus of the re-opened investigation to date has been the review of documentation requested from the Civil Aviation Safety Authority, the operator and other organisations, as well as interviewing a number of personnel from these organisations. These activities are ongoing.

 

________

The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.

 

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.

 

Wreckage of the aircraft off Norfolk Island

 

To download an image click the download link then right-click the image and select save image as.

 

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: 25 May 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: Destroyed 
Departure point:Apia, Samoa
Departure time:0545 UTC
Destination:Norfolk Island

Related links

Download Video - December 2009

Released under s25 of the Transport Safety Investigation Act 2003
 
 
 
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Last update 25 May 2015