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ATSB cites Pel-Air crew errors in 2009 aeromedical ditching

written by australianaviation.com.au | August 31, 2012

VH-NGA, which ditched off Norfolk Island. (Paul Sadler)

An ATSB investigation into the ditching of a Pel-Air aeromedical flight into the ocean off Norfolk Island in 2009 has cited a series of errors by the flight’s crew.

Westwind 1124A VH-NGA was forced to ditch late at night on November 18, 2009 as it ran out of fuel after severe weather prevented the crew from seeing the runway on approach to Norfolk Island from Apia, Samoa. All six passenger and crew were rescued.

The pilot in command of the aircraft, Dominic James, had been hailed as a hero for managing the night ditching without loss of life.

But the ATSB found that James did not plan the flight in accordance with regulatory and operator requirements, nor did the crew have a current weather forecast for Norfolk Island when it made the decision to continue the flight rather than diverting elsewhere. The investigation also found that the flight carried enough fuel for normal operations but not enough to cover an engine failure or de-pressurization.

Further, the ATSB said the crew failed to tell Norfolk Island’s Unicom operator where they were ditching the aircraft, making the subsequent rescue “somewhat fortuitous.”


“The flight crew’s delayed awareness of the deteriorating weather at Norfolk Island combined with incomplete flight planning to influence the decision to continue to the island, rather than divert to a suitable alternate,” the investigation said.

As a result of the incident, the ATSB said Pel-Air had changed its guidance on unforecast weather conditions and would provide satellite communication to crews in remote areas. CASA is also developing regulations covering fuel planning and in-flight management.

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Comments (10)

  • Kenny


    I remember this incident well and was involved in the industry at the time. I also remember that the press tried to make the pilot out to be a hero (because he was a Cleo batchelor of the year contestant) when in actual fact, we all knew it was reckless behaviour on his behalf. Apparently, he was also a coward when the plane ditched leaving the passengers to fend for themselves. I wonder if this clown has still got his pilots licence.

  • Whistle Blower


    What everyone should be asking Mike Watson, the ATSB investigator, and Ian Sansgton (ATSB General Manager Aviation Investigations) is why this final report was issued when it had been brought to their attention that there were inaccuracies, factual errors and evidence in dispute. They had the chance to provide an accurate and factual report but instead chose to issue a report they knew was not correct. Where is the credibility inn ATSB if this is the standard of their reporting? Hopefully the Four Corners report on Monday night will ask some of these questions!

  • facts?


    You obviously have no idea what you are talking about. One could only assume you have an agenda or more than closer to the truth, are are an enthusiastic amateur. Yet another clown involved in this circus!!!

  • Ron


    Play nicely boys.

  • fueldrum


    Why, exactly, was the crew not required to meet ICAO rules for fuel reserves? They were flying in international airspace.

    Secondly, why did CASA approve an ops manual that permitted such a flight to be made without fuel for an alternate destination? Who approved this and why does this person not realise how dangerous that is?

    Finally, who at Pel-Air failed to recognise that ICAO rules apply whenever you are in international airspace, regardless of anything CASA says or does?

  • Ric L


    Whilst there are many contributing factors the pilot is still responsible for the safe operation of his aircraft. Aiming to land on a small runway in the middle of the ocean without an alternate seems really dumb at best or legally culpable at worst. More lucky fool than hero pilot in this case.

  • Hadassah


    Everyone is talking about the pilot to be a hero, and I think his actions in the water are deserving of that, HOWEVER, what about the doctor and the nurse. It was the doctor that risked staying in a sinking plane to get his patient out, no training can prepare you for that. It was the nurse who has had her life ripped apart from being a fun loving, energetic obviously highly trained and skilled nurse to now having to suffer everyday from nerve pain which is the worst pain imaginable.

    More heroes – what about the New Norfolk rescue guys, they risked their own lives to go out to look for what no doubt they thought was wreckage and no survivors in what were terrible conditions.

    It’s easy in hindsight to lay blame when everything is picked apart and examined, but at the end of the day I think they all should be thanking God that a miracle occurred that they all survived. Now we need another miracle that they can all continue on with their lives, pain and bad memory free.

  • John


    Saw the Four Corners program, which raised even more questions. For example, the Unicom operator on Norfolk, clearly a very competent character, is reported to have had a serviceable HF radio but was “not allowed to use it”.

    Why not? If he had used it he should have been able to contact the Westwind well before it was in VHF range and advised the deteriorating conditions on the island.

  • Leon Burger


    I have been a pilot for most of my adult life; 36 years as both military and commercial pilot. As such I have revewed a very large number of air accidents and incidents, been part of the investigation in quite a number of these occurences, and actually been involved in a few.

    Yet I am always amazed at the comments from fellow aviators following and acident/incident. The aim of investigating such occurences is to determine the lessons we can ALL learn from it to prevent re-occurence; not to determine blame. Even when there have been blatant mistakes (pilot errors) we should remember that no person has a death wish and do not deliberately make decisions that could lead to potential disaster.

    I always believe that all aviators make decisions and take actions based on the factors at hand and their best judgement at the time. That such judgement and actions are sometimes wrong is a tragedyand should not be subjected to our derision or scorn.

    Learn from others’ mistakes, guys. That way you will not have to learn from your own mistakes.

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