[Peetwo]

PelAir coverup MKII - Final report released.

Media release

Title
Media statement: AO-2009-072 (reopened)
 
Date: 23 November 2017

The Australian Transport Safety Bureau (ATSB) has today released its final report into the reopened investigation of the 18 November 2009 accident involving Israel Aircraft Industries Westwind 1124A aircraft, VH-NGA, near Norfolk Island.

The flight, which was conducting an air ambulance flight, took off from Apia, Samoa, bound for Australia, via Norfolk Island for a fuel stop. On arrival at Norfolk Island, low cloud prevented the crew from making a safe landing. After four unsuccessful approaches, and with insufficient fuel to divert to another airport, the aircraft was ditched into waters 6.4 km west-south-west of the airport. All six occupants evacuated from the aircraft and were rescued by boat.

The ATSB formally reopened its investigation on 4 December 2014 following criticism of its original investigation by the aviation industry and was subject to an inquiry by the Australian Senate’s Rural and Regional Affairs and Transport References Committee.

Prior to commencing the reopened investigation, the ATSB requested the Transportation Safety Board of Canada (TSB) conduct an independent peer review of its investigation methodologies and processes. Its review, which included an examination of two previous aviation investigations along with the original investigation involving VH-NGA, stated that “The TSB Review compared the two organisations’ methodologies against the standards and recommended practices outlined in Annex 13 to the International Civil Aviation Organization (ICAO) Convention on International Civil Aviation, and found they met or exceeded the intent and spirit of those prescribed.”

However, the review also found deficiencies in how the ATSB’s methodologies were applied in the case of the Norfolk Island investigation and identified 14 recommendations for the ATSB to enhance the quality and the way in which it conducts future safety investigations.

Special measures were taken to ensure the reopened investigation remained distinct from the original and to avoid the possibility of any preconceptions or conflicts of interest. As part of those measures, it was conducted by investigators and overseen by managers who had not been involved in the original investigation. Additionally, the ATSB’s current Chief Commissioner, Greg Hood, was not involved in any part of the investigation, as he had been in a senior role at the aviation regulator, the Civil Aviation Safety Authority (CASA), at the time of the accident.

The new investigation team reviewed evidence obtained during the original investigation and acquired a substantial amount of additional information that was not obtained or available to the original investigation team. This new material included data from the aircraft’s recovered flight recorders and over 30 additional interviews with a range of people, including a number of other Westwind pilots from the operator, inspectors from CASA, as well as re-interviewing the flight crew and medical crew who were on board the aircraft.

The Commission review and approval process of the final investigation report was led by the ATSB’s aviation-experienced Commissioner, Chris Manning.

“This investigation report is one of the largest and most thorough safety investigations the ATSB has completed,” said Commissioner Manning. “The ATSB obtained sufficient evidence to establish findings across a number of lines of enquiry, including relating to individual actions, local contextual factors, the operator’s risk controls and regulatory matters.

The significantly large volume of additional evidence and the complex nature of the analysis of a number of the issues meant that the reopened investigation took longer than originally foreseen.

“The ATSB recognises the importance of being able to demonstrate that the reopened investigation addressed identified areas for improvement with the original investigation.” said Commissioner Manning. “A main focus of the reopened investigation was to address all of the relevant points raised by the Senate inquiry. We have also ensured the specific findings of the TSB’s review were fully taken into account in our final report.”

Commissioner Manning added the thoroughness and level of detail in the final report was substantially more than would normally be the case for a safety investigation of this nature. The final report found 36 safety factors, including 16 safety issues. This large number of safety issues and factors was due in part to the amount of information obtained by the reopened investigation and the depth to which it was analysed.

“The ATSB adopted this approach to address a wide range of matters raised by various parties regarding the original investigation report,” said Commissioner Manning. “The ATSB was mindful at all times that the people and organisations involved in this accident have been intently waiting for the results of the reopened investigation and acknowledges the time that it has taken to complete the final report.”

Commissioner Manning said the most fundamental lesson from this reopened investigation for the regulator, operators and flight crews is to recognise that unforecast weather can occur at any aerodrome and can be especially challenging at remote islands and isolated locations.

“Consequently, there is a need for robust and conservative fuel policies, planning and in-flight management procedures for passenger-carrying transport flights to these types of destinations” said Commissioner Manning.

The final investigation report, AO-2009-072 (reopened), ‘Fuel planning event, weather-related event and ditching involving Israel Aircraft Westwind 1124A aircraft, VH-NGA, 6.4 km WSW of Norfolk Island Airport on 18 November 2009’, has been published on the ATSB’s website.

Editor’s note: Broadcast video and audio grabs of Commissioner Manning are available to media outlets on request by emailing: media@atsb.gov.au
 


Last update 23 November 2017

The following investigation crumbs IMO highlights clearly why the ATSB should be disbanded for at least the Aviation accident investigation ASAP:

ATC weather updates?

Given the huge missed opportunity by ATC to inform the co-pilot and myself of the new TAF which changed the fuel requirements for Norfolk, and that exemptions from ICAO policy have been granted in this regard re informing crew in international operations of such changes, why is a lengthy discussion on this topic missing?

ATSB IIC Dr Walker's nasty and arrogant reply to the above Captain DIP comment:
  

No change required

In addition to the content in The occurrence section, the draft report discusses the provision of flight service in the Nadi and Auckland Oceanic FIRs in detail (about 5 pages). The topic is also discussed in the Safety analysis (2 pages), and findings are included in relation to the Nadi IFISO and Auckland air/ground operator’s actions.

It is not clear what ‘exemptions from ICAO policy’ the captain is referring to. In relation to amended TAFs, ICAO guidance (in document 7030 for most regions) stated that amended TAFs only needed to be passed on when an aircraft was within 60 minutes of its destination. However, this did not apply to the Nadi FIR (although it did apply to the Auckland Oceanic FIR and the Australian FIRs). Overall, the Fijian and New Zealand flight information service providers’ procedures were consistent with ICAO standards and recommended practices.

Limited information about the reasons for the actions of the Nadi IFISO and Auckland air/ground controller regarding VH-NGA on 18 November 2009 were available to the ATSB reopened investigation. The ATSB discussed the topic in as much relevant detail as it could, given the available information. The importance of the meteorological information that was not passed by ATS to the flight crew has also been highlighted in the draft report.

Overall, further discussion of the topic was not considered warranted.

The dismissal by Walker of what essentially is IMO an ATSB identified significant safety issue...

ICAO guidance..(sic)..stated that amended TAFs only needed to be passed on when an aircraft was within 60 minutes of its destination

...is extremely problematic and disturbing in an international perspective.

How hard would it have been for the ATSB to issue a safety recommendation or notice to ICAO suggesting that maybe the document 7030 guidance should be revisited and possibly amended.  

Now from the MKII report some relevant quotes from the Dr Walker referred pages.

From Pg 97:

CAAF also reported:

- The Nadi Air Traffic Management Centre normally received METARs/SPECIs and TAFs within a few minutes of them being sent by the disseminating station.
 - METARs/SPECIs and TAFs were delivered automatically to two printers, including one at the IFISO’s workstation.
 - The IFISO’s workstation was enclosed in a soundproof booth.
 - When SPECIs were received, they were displayed to both the IFISO and the controller.

On 20 November 2009, the ATSB asked CAAF for ATS records for the flight and the weather information that was provided to the flight crew of VH-NGA. CAAF forwarded the request to the ATS provider and then obtained the records in December 2009 to pass on to the ATSB. This included copies of the 0630 METAR, 0800 SPECI and 0830 SPECI.

P2 - Note the non-inclusion of the 0739 SPECI & 0803 AMD TAF. However this was explained in the next paragraph where the timeline of investigation bizarrely seems to jump from the original investigation back to the present reiteration:

CAAF advised it was not aware of the 0739 SPECI and the 0803 amended TAF until it received the ATSB’s investigation report in 2012. CAAF contacted the ATS provider, who advised it had provided CAAF with all the weather reports it had received at the time (in 2009). The ATS provider advised CAAF it no longer held the hard copy print outs and therefore CAAF could not verify whether the 0739 SPECI or the 0803 amended TAF had been received.

Q/ We now know that the ATSB and CASA in their parallel investigation activities were both aware of the existence of at least the 0803 AMD TAF by 23 November 2009. Therefore why did the ATSB in the course of their investigations - especially after receiving the Auckland & Nadi ATC transcripts -  not query the CAAF on why it was they didn't have copies of the 0739 wx report & the 0803 amended forecast?  

Quote from "K" post above - A thumbnail, dipped in tar. - once again the significance of the non-relayed wx report and AMD TAF in the context of this 531 page re-hashed 'the pilot did it' bollocks report...

...The only variable in all of this was the Norfolk Island weather. CASA insist that James should have based his decisions on the weather forecast provided – in flight. The problem is James never received an updated weather forecast until he was past the final, crucial decision gate. Had the 0739 or the 0803 conditions been relayed, before he was committed to Norfolk, a diversion was possible and mandatory. Lots of folk seem to be skipping past this crucial element. I have ‘done the numbers’ and agree with the Davies summary – with one exception. James was ‘fat’ for fuel all the way and dead set ‘legal’ until it was too late; even then, had the gods smiled, he may have ‘squeaked’ in, as many of us have, under the cloud base. Alas….

MTF? MUCH!..P2