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.
__________
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.
