ATSB’s Norfolk Island Ditching Report To Get Scrutiny


The Australian captain of a Westwind jet that ditched off the coast of Norfolk Island in 2009 is challenging the Australian Transport Safety Bureau’s conclusion that the flight crew’s poor planning was the sole cause of the accident. Dominic James, who then worked for Pel-Air, told AVweb in an interview on Saturday that the ATSB’s investigation will undergo its own probe before the Australian Senate in early October. Specifically, James said, the ATSB’s investigation ignored numerous details that impinged on the information and guidance that he and First Officer Zoe Cupit had available for the flight on Nov. 18, 2009. The Westwind crew was on a medical evacuation mission from Apia, Samoa to Melbourne, a distance of about 2,800 miles, almost all of it over water at night. To make the distance, the flight had a planned fuel stop at Norfolk Island, a remote island 800 miles off the coast of eastern Australia.

Although the flight departed with a forecast for good weather at Norfolk Island, the forecast proved erroneous and the Westwind arrived to find low ceilings, poor visibility and rain. Norfolk Island had only a non-precision approach at the time, but the overcast was lower than the approach’s minimum descent altitude. The aircraft had sufficient fuel for three approach attempts and an abbreviated fourth try before James elected to ditch the airplane near the island. Despite moderate seas and poor visibility, all six people evacuated from the aircraft and survived. In its accident report released last month (PDF), the ATSB faulted the crew for not planning the flight in accordance with Australian regulations and Pel-Air operating requirements and said that it failed to aggressively update weather forecasts and reports as the flight progressed toward Norfolk. The ATSB was also critical of the crew for failing to divert to Noumea, in New Caledonia, while it had the fuel to do.

But James is challenging the report on a number of critical issues. He said the ATSB refused to review with the flight crew how it arrived at its fuel reserves calculations, despite being repeatedly asked. James contends that ATSB’s calculations are incorrect and that he planned the flight according to regulations and guidance given him. Further, while passing Fiji, a second divert airport for the flight, the crew was given an incorrect METAR for Norfolk, which understated weather conditions. A subsequent correction, delivered near sunset with garbled HF conditions, was unintelligible to the crew, according to James.

Although regulations allowed the flight to depart without a named alternate, the ATSB claimed that James planned only enough fuel to complete the flight normally, not allowing enough for a potential depressurization event that would have forced it to a lower, less fuel-efficient altitude. The aircraft departed Apia with full main tanks, but empty tip tanks. James told us that with the tips full, the Westwind wouldn’t have been able to climb high enough, soon enough, to realize enough economy to make the additional fuel worth carrying. James also told us the Westwind was not RVSM equipped, even though it was flying in RVSM airspace, a point CASA never enforced with Pel-Air. Normally, that would mean an altitude no higher than FL280, where fuel consumption would be too high to fly the distances required. James said controllers would look the other way if non-RVSM aircraft could get to FL390, which James said the Westwind could do at lighter weights. In any case, he said, Noumea wouldn’t have been an option even with the tip tanks filled because it was 90 degrees to course and too far from Norfolk.

James said the ATSB report pointedly ignores an internal CASA investigation that reveled significant criticism of Pel-Air’s operating methods, one of which was an outdated crew rest rule that allowed duty days as long as 24 hours. The CASA report isn’t mentioned in the ATSB report and was never released to the public. In this program on Australia’s 4Corners broadcast, reporter Jeff Thompson revealed some of the details.

The ATSB report also ignored complaints about poor weather forecasting and METAR dissemination for Norfolk. Moreover, the Norfolk Unicom operator was equipped with an HF radio, but not allowed to use it because of lack of training and licensing.

Survival aspects of the accident that ATSB overlooked, said James, include training that called for placing the life raft, unsecured, near the door. James said this meant that it was immediately lost during impact. Once in the water, the survivors found that life vests rode up and blocked their ears from hearing commands and encouragement and that the lanyards for the vest whistles were too short, requiring survivors to use the whistles on the vests of others. The whistles were the same shape as the manual inflators on the vests, resulting in unintentional deflations in the water.

James told us he’s not trying to alter the report’s conclusion, but merely add factual data that will show the accident was the result of a chain of events that included Pel-Air’s poor policies and CASA’s lack of effective oversight.

“I’m not going to go on record and say I’m not without fault and that I couldn’t have done better,” James told us. “But I totally reject the thrust of the report that makes this wholly the fault of the crew. That’s nuts to me.”

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