australian aviation logo

ATSB releases final report on Pel-Air ditching

written by australianaviation.com.au | November 23, 2017

The Pel-Air Westwind corporate jet at the bottom of the ocean off Norfolk Island. (ATSB)
The Pel-Air Westwind corporate jet at the bottom of the ocean off Norfolk Island. (ATSB)

The Australian Transport Safety Bureau (ATSB) final report into the ditching of a Pel-Air aeromedical flight off the coast of Norfolk Island eight years ago has found the Captain in command made a series of missteps during the flight planning process, while the operator lacked sufficient risk controls in relation to fuel planning and safety.

The ATSB has handed down its final report on the November 18 2009 incident involving a Westwind corporate jet VH-NGA that experienced a controlled ditching into the Pacific Ocean following four unsuccessful attempts to land at Norfolk Island Airport.

Published on Thursday, this new final report comes nearly three years after the ATSB reopened the case in response to a scathing assessment of its original findings. At 531 pages, it is one is one of the longest ever reports produced by the ATSB.

The report found the captain’s preflight planning did not include many of the elements needed to reduce the risk of a long-distance flight to a remote island.

Further, the report also highlighted issues with risk controls at operator Pel-Air.

There were also deficiencies in air traffic services from Nadi and Auckland, which did not provide the flight crew with all the information that should have been provided.

And the ATSB also highlighted limitations in the Civil Aviation Safety Authority’s (CASA) processes for its surveillance and auditing of air operator’s certificate (AOC) holders.


The Westwind corporate jet was flying from Apia, Samoa to Melbourne with six passengers and crew on board – two in the flight deck, a nurse, a doctor, the patient and her husband. The aircraft had planned to make a refuelling stop at Norfolk Island after taking off from Apia.

However, the flight met bad weather resulting in low visibility around Norfolk Island. The flight crew made four unsuccessful attempts to land before ditching the aircraft off the west coast of the island. All six passengers and crew on board survived the crash and were rescued. However, a number sustained serious injuries.

The ATSB said the evacuation of the aircraft was hampered by not having any “formal, specific procedures and limited training regarding 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” as water poured into the cabin.


“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,” the ATSB report said.

The original ATSB report released in 2012 cited errors by the flightcrew and found the pilot in command of the aircraft Dominic James did not plan the flight in accordance with regulatory and operator requirements.

However, the ATSB investigation was strongly criticised by a Senate committee which found, among other things, that the Civil Aviation Safety Authority (CASA) withheld a number of documents critical of Pel-Air. A Four Corners investigation also highlighted serious flaws in the way the investigation was conducted.

In 2014, the ATSB began a fresh investigation, following calls to do so from the Senate Committee and then Deputy Prime Minister and Minister for Infrastructure and Regional Development Warren Truss. As part of the renewed look into the incident, the ATSB retrieved the flight data recorder from the ocean floor.

After nearly three years of work, this final report has again highlighted Captain James’ flight planning missteps before the aircraft left Apia.

“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,” the ATSB report said.

“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.”

The ATSB said the flight crew did not request sufficient information from air traffic services in Nadi and Auckland while enroute to Norfolk Island and prior to passing the point of no return (PNR). Moreover, the Captain did not use an appropriate method for calculating the PNR, the ATSB said.

And once point of no return had passed, meaning landing at Norfolk Island Airport, as opposed to diverting to an alternate airport at Nadi or Noumea, was the only remaining option, the ATSB noted there was still the opportunity 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 ATSB said.

“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 terms of operator Pel-Air, a subsidiary of Regional Express, the ATSB said its 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,” the ATSB said.

“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 said Pel-Air had reviewed and “substantially enhanced its risk controls and management oversight for flight and fuel planning, as well as other areas of its air ambulance operations” following a special audit conducted by CASA.

Meanwhile, the report noted that CASA in 2014 modified its requirements for operations to Australian remote islands.

However, CASA’s proposed change of regulatory classification of air ambulance or medical transport flights from “aerial work” to “air transport” first announced in 2012 was yet to take place.

“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 said.

“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.”

The full report can be read on the ATSB website.

Comments (3)

  • Chris Grealy


    Another report as a result of political interference; with many more pages but pretty much the same conclusions as the first, as far as I can see. Whatever this cost, I doubt that the politicians involved will ever read it. Such wise use of limited resources, not!

  • D W Bell


    Clearly the balance of needing to get expereince verses actually having expereince is a fine line. Regardless of weather an air operator has a procedure or not, the pilots should have recognised, in part from flying the outbound leg, what the requirements may have been in returning and therefore made suitable adjustments to the flight plan including fuel burn requirements. Physics is a strange beast, but if the motors don’t have the gas then it is very difficult to maintain any form of forward movement. From reading a number of view points and understanding a little bit about flying requirments 2 equal but different causal factors. In sufficient Safe systems of work on the part of the operator and B) lack of expereince on the aprt of the crew.

  • Pontius the pilot


    The investigation lost the plot at the start.. Australia is about the only State (an ICAO term) that has lodged a difference with Annex 6 of the ICAO convention, that requires all I repeat ALL IFR flights to carry an alternate.

    Sure there are in flight replanning work arounds, but in the Norfolk case, the only option under international rules is to depart carrying a mainland alternate. CASA fuel policy is primarily at fault. It is amazing that no one picked up on this.

Leave a Comment to Pontius the pilot Cancel

Your email address will not be published. Required fields are marked *

Each day, our subscribers are more informed with the right information.

SIGN UP to the Australian Aviation magazine for high-quality news and features for just $99.95 per year

You don't have credit card details available. You will be redirected to update payment method page. Click OK to continue.