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What happened

On 18 November 2009, an Israel Aircraft Industries Westwind 1124A aircraft, registered VH-NGA, was operated on an air ambulance flight from Apia, Samoa to Norfolk Island, Australia. Two flight crew, a doctor, a flight nurse, a patient and a passenger (the patient’s husband) were on board.

On arrival at Norfolk Island at night, there was low cloud and the aircraft had insufficient fuel to divert to another airport. After four unsuccessful approaches, the flight crew ditched the aircraft 6.4 km west-south-west of the airport.

During the ditching, the aircraft encountered significant impact forces, and the flight nurse and first officer were seriously injured. The aircraft cabin rapidly flooded, and all six occupants evacuated from the aircraft, but with only three of the six life jackets on board and neither of the aircraft’s life rafts. The evacuees were rescued 85 minutes later by personnel on a search vessel launched from Norfolk Island.

What the ATSB found

The flight crew were conducting a long-distance flight to a remote island at night. At the time the flight was planned, the aerodrome forecast for Norfolk Island indicated the weather conditions at the time of arrival would be above the alternate minima.

Contrary to the consistent practice of the operator’s Westwind fleet for such flights, the flight departed with full main tanks (or about 7,200 lb of fuel) rather than full main tanks and tip tanks (about 8,700 lb). The reasons why the captain elected to depart without the maximum fuel load on this occasion were not fully determined. However, the ATSB found the captain’s pre-flight planning did not include many of the elements needed to reduce the risk of a long-distance flight to a remote island. These included miscalculating the total fuel required for normal operations, not calculating the additional fuel required for aircraft system failures, not obtaining relevant forecasts for upper-level winds, and not obtaining current information about potential alternate aerodromes. Although there was no requirement for the flight to depart with alternate or holding fuel, the fuel on board was insufficient to meet operator and regulatory requirements for the flight to allow for aircraft system failures.

Although the operator’s Westwind pilots generally used a conservative approach to fuel planning, the operator’s risk controls did not provide assurance there would be sufficient fuel on board flights to remote islands or isolated aerodromes. Limitations included no explicit fuel planning requirements for such flights, no formal training for planning such flights, no formal guidance information about hazards at commonly-used aerodromes, no procedure for a captain’s calculation of the total fuel required to be checked by another pilot, and little if any assessment during proficiency checks of a pilot’s ability to conduct fuel planning.

There were also limitations with Australian regulatory requirements. Other than requirements for fuel planning of passenger-carrying charter flights to remote islands, there were no explicit fuel planning requirements for other passenger-carrying flights to remote islands, and no explicit requirements for planning flights to isolated aerodromes. In addition, air ambulance flights were classified as ‘aerial work’ rather than ‘charter’. Consequently, they were subject to a lower level of requirements than other passenger-transport operations (including requirements for fuel planning).

During the flight, the weather conditions at Norfolk Island deteriorated below the landing minima. Air traffic services in Nadi and Auckland did not provide the flight crew with all the information that should have been provided. In addition, the flight crew did not request sufficient information prior to passing the point of no return (PNR), and the captain did not use an appropriate method for calculating the PNR. Related to these actions, the operator’s risk controls did not provide assurance that its pilots would conduct adequate in-flight fuel management activities during flights to remote islands or isolated aerodromes. The Civil Aviation Safety Authority (CASA) had also published limited guidance material regarding in-flight fuel management.

After the aircraft passed the PNR, there were opportunities to minimise the risk associated with the developing situation. However, the flight crew did not effectively discuss approach options, and they did not effectively review their fuel situation and consider alternate emergency options prior to ditching the aircraft. The flight crew did not refer to the ditching checklist and the final approach was conducted at an airspeed significantly below the reference landing speed (VREF), which increased the descent rate just prior to impact. A range of local conditions influenced the performance of the crew during the latter stages of the flight, including workload, stress, time pressure and dark night conditions.

In addition to the rapid flooding of the aircraft cabin, the occupants’ evacuation was hampered by there being no formal, specific procedures and limited training regarding on how to secure life rafts in an appropriate, readily accessible location prior to a ditching, and a designated storage location for the stretchered patient’s life jacket. In very difficult circumstances, the nurse and doctor did an excellent job evacuating the patient, and then assisting the injured first officer and the patient in the water, both of whom did not have life jackets.

Due to the inherent limitations of most emergency locator transmitters (ELTs) for a submerged aircraft, and the limited information provided by the flight crew regarding the location of the ditching, search and rescue personnel initially had no reliable information about where to search for the aircraft. It was fortunate that a firefighter made a chance sighting of the captain’s torch, resulting in the search effort being redirected to the appropriate area and the successful rescue of the evacuees.

In addition to issues associated with fuel planning and in-flight fuel management, the ATSB identified safety issues with the operator’s risk controls for emergency procedures and training, fatigue management, crew resource management training and flight crew training for newly-installed systems on the accident aircraft. The ATSB also identified limitations with the operator’s hazard identification processes and the definition of roles and responsibilities of key management personnel, and the processes used for the operator and air ambulance provider for conducting pre-flight risk assessments. Limitations were also identified with the processes used by CASA for planning surveillance, scoping audits and conducting audits.

What's been done as a result

Following the accident, CASA conducted a special audit of the operator, and this audit involved an extensive assessment of the operator’s air ambulance operations. The operator voluntarily ceased its Westwind operations and collaborated with CASA during the audit. During this process, the operator reviewed and substantially enhanced its risk controls and management oversight of flight/fuel planning and in-flight fuel management. It also enhanced its risk controls and management oversight of many other areas of its air ambulance operations.

In 2014, CASA modified the requirements for operations to Australian remote islands, so that all passenger-carrying transport flights, including air ambulance flights, were required to depart with alternate fuel. In addition, in 2012 CASA initiated action to change the regulatory classification of air ambulance (or medical transport) flights from aerial work to air transport. However, although CASA released a Notice of Proposed Rule Making about this issue in 2013, no changes have yet occurred. Accordingly, the ATSB issued a safety recommendation to CASA to continue reviewing the requirements for air ambulance operations and address the limitations associated with the current classification of these flights. The ATSB also issued two other recommendations to CASA for it to continue its activities to address the limitations with the requirements and guidance for fuel planning of flights to isolated aerodromes and the requirements and guidance of in-flight fuel planning.

In addition to these actions, since 2009 there have been improvements in a range of other areas. These include improvements to CASA’s surveillance processes, weather forecasting processes at Norfolk Island, and the publishing of advisory information about the hazards at remote island aerodromes. In addition, there now exists an enhanced capability for satellites to detect the location of ELT signals from aircraft involved in ditchings and similar impacts where the ELTs are unable to emit signals for extended periods.

Safety message

The investigation report contains 36 safety factors that provide lessons to flight crews, operators, regulators and/or other organisations. Overall, the most fundamental lesson for all flight crew, operators and regulators is to recognise that unforecast weather can occur at any aerodrome. Consequently, there is a need for robust and conservative fuel planning and in-flight fuel management procedures for passenger-transport flights to remote islands and isolated aerodromes.

Additional safety messages include:

  • Flight crew should discuss and consider options to manage threats when there is time available to do so.
  • Operators should ensure their flight crew proficiency checks assess the performance of all key tasks required of their flight crew.
  • Operators should not rely on informal risk controls for managing the performance of safety-critical tasks, particularly when there is significant turnover of pilots in a fleet.
  • Operators of air ambulance flights should ensure medical personnel have clearly defined procedures and appropriate practical training for using the emergency equipment on board to ensure they can effectively assist a patient in the event of an emergency.
  • All organisations in safety-critical industries should use proactive and predictive processes to identify hazards in their operations.
  • Organisations that use a bio-mathematical model of fatigue as part of their fatigue risk management system should ensure they have a detailed understanding of the assumptions and limitations associated with such models.
  • Regulators should develop effective methods for obtaining, storing and integrating information about operators and the nature of their operations so that they can develop effective surveillance plans.
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Background

On 18 November 2009, an Israel Aircraft Industries Westwind 1124A aircraft, registered VH-NGA and operated by Pel-Air Aviation Pty Limited, was being flown on an air ambulance flight from Apia, Samoa to Norfolk Island, Australia. Two flight crew, a doctor, a flight nurse, a patient and a passenger (the patient’s husband) were on board. After the crew were unable to land due to low cloud, they ditched the aircraft 6.4 km west-south-west of the airport. Two of the occupants were seriously injured, and the aircraft cabin rapidly flooded and sank in 48 m of water. All the occupants evacuated from the aircraft and were later rescued by personnel on a search vessel launched from Norfolk Island.  

The Australian Transport Safety Bureau (ATSB) conducted a safety investigation, numbered AO-2009-072, into the accident. It released its draft report to directly involved parties in March 2012, and its final report in August 2012. Shortly after the release of the final report, a television program questioned the quality and findings of the investigation.

Soon after, the Australian Senate’s Rural and Regional Affairs and Transport References Committee commenced an inquiry to examine the findings of the ATSB’s report, the investigation process and related matters. The Committee’s report, released in May 2013, made a number of recommendations to the Australian Government, the ATSB and other government agencies. These included recommendations about ATSB’s investigation processes, as well as the following specific recommendations regarding the AO-2009-072 investigation:

The committee recommends that the ATSB retrieve VH-NGA flight data recorders without further delay…

The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues.

Following the Senate inquiry report, the ATSB requested the Transportation Safety Board of Canada (TSB) to conduct an independent peer review of the ATSB’s investigation methodologies and processes. The review included an examination of the ATSB’s investigation process applied during three investigations, including AO-2009-072.

The TSB finalised its report on 1 December 2014.[1] Although the TSB review provided generally favourable comment on the ATSB’s investigation processes and methodologies, it noted significant limitations with the ATSB’s application of its processes during the Norfolk Island investigation. A key problem was insufficient collection of factual information in several areas.

On 4 December 2014, the ATSB formally reopened investigation AO-2009-072. The reopened investigation reviewed the evidence obtained during the original ATSB investigation, as well as additional evidence and other relevant points raised in the TSB review, the Senate inquiry and through the Deputy Prime Minister’s Aviation Safety Regulation Review. The main focus was on ensuring that the specific findings of the TSB and other reviews were taken fully into account before issuing a final report of the reopened investigation.

The reopened investigation obtained a substantial amount of information that was not obtained or available to the original investigation. This included additional information on:

  • 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 training and checking
  • 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 additional data collection activities included:

  • recovering and downloading the data from the aircraft’s cockpit voice recorder and flight data recorder
  • reviewing documentation from investigations into the accident conducted by the Civil Aviation Safety Authority (CASA) and the operator, including interviews conducted with the flight crew
  • re-interviewing the flight crew, doctor and flight nurse of the aircraft, and interviewing a significant number of the operator’s Westwind pilots, management personnel and safety personnel
  • reviewing documentation from the operator, including flight records for several Westwind aircraft, training and checking records for several flight crew, duty times and rosters for other flight crew, occurrence and hazard reports, internal and external audit reports, and safety committee meeting records
  • interviewing several personnel from the CASA
  • reviewing CASA’s files on the operator’s flight operations since 2000, including the files associated with the special audit CASA conducted on the operator immediately following the accident
  • 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
  • recovering and examining the three life jackets used by occupants of the aircraft
  • obtaining information from several other organisations, including the aircraft manufacturer, the Bureau of Meteorology, Airservices Australia, the life jacket manufacturer and the air ambulance provider (CareFlight).

The reopened investigation was conducted by ATSB investigators, and oversighted by ATSB managers who were not involved in the original investigation. In addition the Commission review and approval process was led by the ATSB’s aviation experienced commissioner, noting that by the time this process commenced, the incumbent Chief Commissioner was a previous senior officer in CASA, including at the time of the accident. The Chief Commissioner formally declared this potential conflict of interest at the time of his appointment and recused himself from any involvement with the reopened investigation. Independent investigators from the Department of Defence Directorate of Defence Aviation and Air Force Safety (DDAAFS) were witness to the download of the cockpit voice recorder and flight data recorder information.

Due to the time elapsed since the accident, the reopened investigation was not able to obtain or had difficulty obtaining some types of information (such as flight recorder data or air traffic control data for other flights). In addition, the recollection of people interviewed regarding some events and conditions in the period prior to the accident was limited. Nevertheless, the ATSB was able to obtain a substantial amount of useful information, and is satisfied that this information was adequate to appropriately examine the lines of inquiry of the reopened investigation and to support the report’s findings.

Based on all the available information, the final report of the reopened investigation includes many more findings than the original investigation. In addition, the level of detail in this report on some topics is substantially more than would normally be the case for a safety investigation report. The ATSB adopted this approach to address a wide range of matters raised by various parties regarding the original investigation report.

 

____________
[1]
    Transportation Safety Board of Canada 2014, Independent review of the Australian Transport Safety Bureau’s investigation methodologies and processes. Available at www.bst-tsb.gc.ca.

 

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. Screen capture from Victoria Police ROV.

 
 

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Safety issues

AO-2014-190-SI-01 - AO-2014-190-SI-02 - AO-2014-190-SI-03 - AO-2014-190-SI-04 - AO-2014-190-SI-05 - AO-2014-190-SI-06 - AO-2014-190-SI-07 - AO-2014-190-SI-08 - AO-2014-190-SI-09 - AO-2014-190-SI-10 - AO-2014-190-SI-11 - AO-2014-190-SI-12 - AO-2014-190-SI-13 - AO-2014-190-SI-14 - AO-2014-190-SI-15 - AO-2014-190-SI-16 -  

Operator’s risk controls for flight/fuel planning

The operator’s Westwind pilots generally used a conservative approach to fuel planning, and the operator placed no restrictions on the amount of fuel that pilots uploaded. However, the operator’s risk controls did not provide assurance that there would be sufficient fuel on board flights to remote islands or isolated aerodromes. Limitations included:

  • no explicit fuel planning requirements for remote islands or isolated aerodromes
  • no formal fuel planning guidance for some relevant situations, such as a loss of pressurisation or flight below reduced vertical separation minimum (RVSM) airspace
  • no formal training for planning flights to remote islands or for international operations
  • no guidance information about potential hazards at commonly-used aerodromes
  • no procedure for a captain’s calculation of the total fuel required to be checked by another pilot
  • little if any assessment during proficiency checks of a pilot’s ability to conduct flight/fuel planning.
Safety issue details
Issue number:AO-2014-190-SI-01
Who it affects:Operator’s Westwind flight crew
Status:Adequately addressed


 

Operator’s risk controls for in-flight fuel management

The operator’s policies, procedures, training and guidance did not provide assurance that the operator’s Westwind pilots would conduct adequate in-flight fuel management and related activities during flights to remote islands or isolated aerodromes. Limitations included:

  • no formal guidance material about how to calculate a point of no return (PNR) for an off-track alternate aerodrome
  • no formal guidance material regarding what types of weather information to obtain during a flight and when to obtain the information
  • no procedures for a captain’s calculation of the PNR to be checked by another pilot
  • little if any assessment during proficiency checks of a pilot’s ability to calculate a PNR and conduct in-flight fuel management on long distance flights
  • no fitment of a satellite-phone in most of the operator’s Westwind aircraft.
Safety issue details
Issue number:AO-2014-190-SI-02
Who it affects:Operator’s Westwind flight crew
Status:Adequately addressed


 

Pre-flight risk assessments for air ambulance tasks

The operator and air ambulance provider did not have a structured process in place to conduct pre-flight risk assessments for air ambulance tasks, nor was there any requirement for such a process.

Safety issue details
Issue number:AO-2014-190-SI-03
Who it affects:Operator’s Westwind flight crew
Status:No longer relevant


 

Operator’s emergency procedures and cabin safety

The operator’s risk controls did not provide assurance that the occupants on an air ambulance aircraft would be able to effectively respond in the event of a ditching or similar emergency. Specific examples included:

  • insufficient information provided during pre-flight safety demonstrations and the passenger safety brief card to demonstrate how to use a life jacket
  • limited procedures and guidance regarding the relative roles, responsibilities and required actions of flight crew and medical personnel during emergencies, particularly with regard to the evacuation of a patient
  • no practical training or demonstrations for medical personnel on how to use the safety equipment on board the aircraft
  • no designated location for a stretchered patient’s life jacket
  • no formal, specific procedures and limited training on how to secure life rafts in an appropriate, readily accessible location prior to a ditching.
Safety issue details
Issue number:AO-2014-190-SI-04
Who it affects:Operator’s Westwind flight crew and medical personnel on air ambulance flights.
Status:Adequately addressed


 

Operator’s crew resource management training

Although the operator provided its flight crew with basic awareness training in crew resource management (CRM), it was limited in nature and did not ensure flight crew were provided with sufficient case studies and practical experience in applying relevant CRM techniques.

Safety issue details
Issue number:AO-2014-190-SI-05
Who it affects:Operator’s Westwind flight crew
Status:Adequately addressed


 

Operator’s fatigue management

The operator’s application of its fatigue risk management system overemphasised the importance of scores obtained from a bio-mathematical model of fatigue (BMMF), and it did not have the appropriate expertise to understand the limitations and assumptions associated with the model. Overall, the operator did not have sufficient risk controls in addition to the BMMF to manage the duration and timing of duty, rest and standby periods.

Safety issue details
Issue number:AO-2014-190-SI-06
Who it affects:Operator’s Westwind flight crew
Status:Adequately addressed


 

Operator’s installation of new aircraft systems on VH-NGA

Although the operator installed an enhanced ground proximity warning system (EGPWS) and traffic alert and collision avoidance system (TCAS) on VH-NGA in August 2009, it did not provide relevant flight crew with formal training on using these systems, or incorporate relevant changes into the aircraft’s emergency procedures checklists.

Safety issue details
Issue number:AO-2014-190-SI-07
Who it affects:Operator’s Westwind flight crew
Status:Adequately addressed


 

Operator’s hazard identification processes

Although the operator’s safety management processes were improving, its processes at the time of the accident for identifying hazards extensively relied on hazard and incident reporting, and it did not have adequate proactive and predictive processes in place. In addition, although the operator commenced air ambulance operations in 2002, and the extent of these operations had significantly increased since 2007, the operator had not conducted a formal or structured review of its risk controls for these operations.

Safety issue details
Issue number:AO-2014-190-SI-08
Who it affects:Operator’s flight crew and other operational personnel
Status:Adequately addressed


 

Operator’s roles and responsibilities of key personnel

The operator had not formally defined the roles and responsibilities of key positions involved in monitoring and managing flight operations, such as the standards manager for each fleet and the General Manager Flying Operations (Medivac and Charter).

Safety issue details
Issue number:AO-2014-190-SI-09
Who it affects:Operator’s flight crew and other operational personnel
Status:Adequately addressed


 

Regulatory requirements and guidance for fuel planning of flights to remote islands and isolated aerodromes

Although passenger-carrying charter flights to Australian remote islands were required to carry alternate fuel, there were no explicit fuel planning requirements for other types of other passenger-carrying flights to remote islands. There were also no explicit Australian regulatory requirements for fuel planning of flights to isolated aerodromes. In addition, Australia generally had less conservative requirements than other countries regarding when a flight could be conducted without an alternate aerodrome.

Safety issue details
Issue number:AO-2014-190-SI-10
Who it affects:All operators and flight crew who conduct flights to remote or isolated aerodromes


 

Regulatory requirements and guidance for in-flight fuel management

The available regulatory guidance on in-flight fuel management 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.

Safety issue details
Issue number:AO-2014-190-SI-11
Who it affects:All operators and flight crew, particularly those who conduct flights to remote or isolated aerodromes


 

Classification of air ambulance operations

Although air ambulance flights involved transporting passengers, in Australia they were classified as ‘aerial work’ rather than ‘charter’. Consequently, they were subject to a lower level of regulatory requirements than other passenger-transport operations (including requirements for fuel planning flights to remote islands).

Safety issue details
Issue number:AO-2014-190-SI-12
Who it affects:All operators and flight crew that conduct air ambulance operations


 

Regulatory surveillance – surveillance planning

Although the Civil Aviation Safety Authority (CASA) collected or had access to many types of information about a charter and/or aerial work operator, the information was not integrated to form a useful operations or safety profile of the operator. In addition, CASA’s processes for obtaining information on the nature and extent of an operator’s operations were limited and informal. These limitations reduced its ability to effectively prioritise surveillance activities.

Safety issue details
Issue number:AO-2014-190-SI-13
Who it affects:All operators
Status:Adequately addressed


 

Regulatory surveillance – scoping of audits

The Civil Aviation Safety Authority’s procedures and guidance for scoping an audit included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

Safety issue details
Issue number:AO-2014-190-SI-14
Who it affects:All operators
Status:Adequately addressed


 

Regulatory surveillance – assessing process in practice

Consistent with widely-agreed safety science principles, the Civil Aviation Safety Authority’s approach to surveillance of larger charter operators had placed significant emphasis on systems-based audits. However, its implementation of this approach resulted in minimal emphasis on evaluating the actual conduct of line operations (or ‘process in practice’).

Safety issue details
Issue number:AO-2014-190-SI-15
Who it affects:All operators
Status:Adequately addressed


 

Guidance information on the limitations of FAID

Guidance material associated with the FAID bio-mathematical model of fatigue did not provide information about the limitations of the model when applied to roster patterns involving minimal duty time or work in the previous 7 days.

Safety issue details
Issue number: AO-2014-190-SI-16
Who it affects:All operators and flight crew: Air transport and general aviation
Status:Adequately addressed

 
General details
Date: 18 November 2009 Investigation status: Completed 
Time: 1026 UTC Investigation type: Occurrence Investigation 
Location   (show map):6.4 km WSW of Norfolk Island Airport Occurrence type:Low fuel 
State: External Territory Occurrence class: Operational 
Release date: 23 November 2017 Occurrence category: Accident 
Report status: Final Highest injury level: Serious 
 
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

Media statement

Released: 23 November 2017
 
 
 
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Last update 23 November 2017