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Last updated: 13 December 2018
Status:Schlussbericht
Datum:Mittwoch 18 November 2009
Zeit:21:56
Flugzeugtyp:Silhouette image of generic WW24 model; specific model in this crash may look slightly different
IAI 1124A Westwind II
Fluggesellschaft:Pel-Air
Kennzeichen: VH-NGA
Werknummer: 387
Baujahr: 1983
Betriebsstunden:21528
Anzahl Zyklen der Zelle:11867
Triebwerk: 2 Garrett TFE731-3-1G
Besatzung:Todesopfer: 0 / Insassen: 2
Fluggäste:Todesopfer: 0 / Insassen: 4
Gesamt:Todesopfer: 0 / Insassen: 6
Sachschaden: schwer beschädigt
Konsequenzen: Written off (damaged beyond repair)
Unfallort:5 km (3.1 Meilen) SW vom Land entfernt von Norfolk Island Airport (NLK) (   Norfolk Island)
Flugphase: Landung (LDG)
Betriebsart:Ambulanz
Flug von:Apia-Faleolo Airport (APW/NSFA), West-Samoa
Flug nach:Norfolk Island Airport (NLK/YSNF),
Unfallbericht:
An IAI 1124A Westwind II jet, registered VH-NGA and operating under the instrument flight rules (IFR), was ditched 3 km south-west of Headstone Point, Norfolk Island after a flight from Apia-Faleolo Airport (APW). The two flight crew, doctor, flight nurse, patient and one passenger all escaped from the ditched aircraft and were rescued by boat crews from Norfolk Island.
On 17 November 2009, the airplane an aeromedical retrieval operation from Sydney, NSW, Australia to Samoa with an en route stop at Norfolk Island.
The next day the flight was to return to Norfolk Island and then to continue to Melbourne. Departure time from Samoa was 05:45 UTC, and the plane initially climbed to a cruising altitude of FL350 and later to FL390. En route the 80 kts headwind was greater than expected, resulting in a revised ETA of 09:30 UTC, 30 minutes later than planned.
During the flight the crew were advised of deteriorating weather conditions at Norfolk Island. The crew had increasing concerns about their fuel reserves. The crew later indicated that the higher-than-expected en route winds, and not knowing the winds for an off-track diversion, reinforced their doubt. The crew stated that they decided to continue to Norfolk Island because, on the basis of the observed weather conditions at the island being above the landing minima, they expected to be able to land safely. They believed that action was safer than a longer off-track diversion to Noumea, with at that stage unknown destination weather and marginal fuel remaining.
At 09:28, when about 160 NM (296 km) from Norfolk Island, the flight crew was advised by the airport’s Unicom operator about the presence of Broken cloud at 300 ft, 800 ft and 1,100 ft above the airport and visibility 6,000 m. That was, the observed weather was below the landing minima.
The copilot planned to conduct a runway 29 VOR/DME instrument approach. The crew reported agreeing that the expected weather would mean that visual reference with the runway may be difficult to obtain, and that the pilot-in-command (PIC) would closely monitor the approach by the copilot. During the briefing for the first approach, the crew agreed that, if visual reference with the runway was not obtained, the PIC would take over control of the aircraft for any subsequent approaches.
The Unicom operator contacted the crew again at 09:38 and stated that the weather conditions had deteriorated because a rainstorm was 'going through'.
The flight crew initiated a missed approach procedure from the first approach at 10:04:30. The flight crew reported that the PIC then assumed control of the aircraft as agreed during the pre-descent briefing. At 10:13, the flight crew initiated a second missed approach for runway 29 as they did not obtain the required visual references before the missed approach point.
The flight crew then elected to conduct a VOR approach to runway 11 (in the opposite direction) to take advantage of the lower landing minima for that approach. The runway 11 VOR permitted the aircraft to be flown to 429 ft above the runway threshold and to continue for a landing with a visibility of 3,000 m; however, there was a tailwind of up to 10 kts for operations to runway 11. The crew did not obtain the required visual references from the approach and initiated a missed approach procedure at 10:19.
At this time, the flight crew decided that they would ditch the aircraft in the sea before the fuel was exhausted. The copilot briefed the doctor and the passenger who was sitting in the front left cabin seat to prepare for a ditching. At 10:19, the crew reported to the Unicom operator that "we’re going to have to ditch we have no fuel".
The flight crew decided to conduct one more instrument approach for runway 29 as, if they did not become visual off that approach, the missed approach procedure track of 273 °(M)would take the aircraft to the west of Norfolk Island, over open sea and clear of any obstacles for the planned ditching.
The PIC reported descending the aircraft to a lower height than the normal minimum descent altitude for the runway 29 VOR approach procedure in a last attempt to become visual. The crew did not become visual and at 10:25 the PIC made a fourth missed approach and the Unicom operator was notified that they were "...going to proceed with the ditching".
The airplane was configured for landing, without extending the landing gear, and was ditched off shore.

On 4 December 2014, the ATSB formally reopened the investigation following a parliamentary inquiry.
On 11 November 2015, the rear section of the aircraft which contained the flight recorders, was salvaged and both recorders were recovered.

Probable Cause:

CONTRIBUTING SAFETY FACTORS:
- The pilot in command did not plan the flight in accordance with the existing regulatory and operator requirements, precluding a full understanding and management of the potential hazards affecting the flight.
- The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination.
- 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.

Accident investigation:
cover
Investigating agency: ATSB
Status: Investigation completed
Duration: 8 years
Accident number: AO-2009-072
Download report: Final report

Informationsquelle:
» SKYbrary 
» Australian Senate Committee into Aviation Accident Investigations


Sicherheitsempfehlungen
The ATSB report into the accident was disputed by the captain of the accident flight. An Australian Senate Committee into Aviation Accident Investigations was tasked to review the report and to a.o. investigate the nature of, and protocols involved in, communications between agencies and directly interested parties in an aviation accident investigation and the reporting process.q

Fotos

photo of IAI 1124A Westwind II VH-NGA
photo of IAI 1124A Westwind II VH-NGA
photo of IAI 1124A Westwind II VH-NGA
photo of IAI 1124A Westwind II VH-NGA
photo of IAI 1124A Westwind II VH-NGA
photo of IAI 1124A Westwind II VH-NGA
photo of IAI 1124A Westwind II VH-NGA
Approach patterns flown
photo of IAI 1124A Westwind II VH-NGA
Last approach flown
photo of IAI 1124A Westwind II VH-NGA
Cockpit Voice Recorder (CVR)
photo of IAI 1124A Westwind II VH-NGA
Flight Data Recorder (FDR)
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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Apia-Faleolo Airport to Norfolk Island Airport as the crow flies is 2659 km (1662 miles).
Accident location: Approximate; accuracy within a few kilometers.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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