The most damning thing about the ATSB final report into the ditching and sinking of a Pel-Air operated air ambulance flight near Norfolk Island in November 2009 is that CASA, the air safety regulator, almost three years later, hasn’t enforced the same flight safety standards on such operations as it requires from normal passenger jet services.

Instead the report, which is a masterclass in how to write commercially inoffensive copy that will avoid raising public concerns, notes only that CASA has “advised of their intent to regulate Air Ambulance/Patient transfer operations in proposed Civil Aviation Safety Regulations …. to safety standards that are similar to those for passenger operations.”

Intent? In darkness and in wild weather conditions, on 18 November 2009, a small Westwind corporate jet fitted out for a medical relocation flight, took off without adequate fuel to complete its initial journey from Apia to Norfolk Island according to the diversionary or mechanical failure issues which are taken into account as a compulsory requirement by normal airline operations.

As the report says:


In the event, given the forecast in‑flight weather, aircraft performance and regulatory requirements, the flight crew departed Apia with less fuel than required to safely complete the flight in case of one engine inoperative or depressurised operations from the least favourable position during the flight. If the flight had been a passenger-carrying charter flight, the regulations would have required the PIC to carry sufficient fuel to allow for a diversion from the destination to an alternate aerodrome.

Which also means CASA’s rules, contrary to the posturing of the safety regulator after the accident, were so weak that Pel-Air wasn’t obliged to carry enough fuel for a diversion caused by weather or other circumstances right up to the point where it overflew its intended destination.

But three years later, CASA ‘intends’ to fix the problem.

This triumph of prompt regulatory intervention, follows an incident in which poor pilot decision making by an apparently fatigued Pel-Air employee, resulted in six people, comprising two pilots, a nurse, an attendant, a patient, and her companion, flying four missed approaches to the Norfolk Island airstrips, and then making a controlled water landing at around 160 kmh after which the jet broke into two parts and sank 48 metres to the sea bed, leaving those on board to tread water or cling to wreckage before being found by a boat that had been looking in the wrong area when its skipper fortuitously glimpsed the pilot’s torch from afar.

It also confirms the truth of the astonishing comment by Pel-Air chairman, John Sharp, the morning after the near disaster, that the pilot, Dominic James, had set off from Apia with no plan B in the event that the flight couldn’t land on the island where it was to refuel.

There are parts of the developed world where this level of regulatory and operational performance would offend aviation law.  But not in Australia.

General media interest may be focused on what happened in the tiny jet immediately after it crashed.

It details how the captain left the jet first, after working his way rearwards through the cabin, and difficulties the passengers encountered in the short time before they escaped, and how the female co-pilot found herself alone in the cockpit which was filling with water, and fought her way to the surface.

Pilot in command

The PIC reported checking that the copilot was responding before moving rearwards into the cabin and ascertaining that the main door was not usable. Continuing rearwards to the two emergency exits in the fuselage centre section, the PIC opened the port (left, looking forward) emergency exit, and exited as water flowed in through the door opening.

Flight nurse, doctor and patient

The patient’s stretcher was positioned in the area of the starboard (right) emergency exit. That area was reported to have become very crowded and busy as the medical staff released the patient from the stretcher.

The doctor released the patient’s harnesses and opened the starboard emergency exit. Water flowed through the emergency exit and the doctor believed that the door opening was completely underwater. The nurse, doctor and patient exited the aircraft through the starboard emergency exit. All three reported holding onto each other as they departed ‘in a train’ but could not provide a consistent recollection of the sequence in which they exited the aircraft.


The copilot recalled being alone in the cockpit before moving to the main door and attempting unsuccessfully to open it. The copilot reported that the fuselage then tilted nose downward and that a quantity of equipment and baggage descended or rolled down the fuselage as it filled with water. The copilot abandoned the main door, swam up towards the rear of the fuselage, located an emergency exit door by touch, and exited the aircraft.


When the passenger, who was seated immediately behind the main door on the left of the aircraft, released his seat belt, there was little breathing room between the surface of the incoming water and the top of the fuselage. The passenger stated that there was no light and that the nose of the aircraft had tipped down. The passenger recalled swimming rearwards along the fuselage until he felt an emergency exit door and then exiting the aircraft, probably through the port emergency exit.

The passenger believed that he swam upwards some distance after exiting the aircraft before reaching the surface of the water.

Post exit

All of the aircraft occupants stated that they exited the aircraft very quickly, and that there had been no time to take the life rafts. The PIC stated that he returned to the aircraft in an attempt to retrieve a life raft but the 1.5 m to 2 m swell and the jagged edges surrounding the broken fuselage made it hazardous to be near the aircraft, so he abandoned any attempt to retrieve a raft.

The Pel-Air report should thus be studied very closely for what it actually says, as well as what it means.

It shows that the safety regulator is being dragged into a position of conceding that air ambulance passengers are second class citizens when it comes to rules that seemed framed to suit so called aerial work operators rather than anyone who might have thought it regarded the safety of all users of commercial services in Australia as being of equal importance.

The final report discusses the probability that the two pilots were fatigued during the sector from Apia to Norfolk Island but doesn’t come to firm conclusions about this, although it pursues the issue at some length as being a potential factor in their inability to understand weather warnings on route about deteriorating conditions including specific advice to consider an alternative airport.

Instead it shows how the crew decided that the risks of diverting to Noumea exceeded the risks of continuing to Norfolk Island, and it also notes that the pilot in command said that had he filled the wing tip tanks on the jet rather than leaving them empty, the higher weight of the jet on departure from Apia would have increase its fuel consumption.

That argument about why the wing tip tanks in the jet were left empty is to put it bluntly, ripped apart by the ATSB analysis of the fuel decisions that were taken and which from the outset, left the flight inadequately fueled to deal with the contingencies which fuel rules are framed to address.

However while the ATSB report nails the pilot in command for his mistaken fuel logic, it doesn’t discuss the ultimate legal responsibility that Pel-Air had for the professionalism or competency of the pilot in being put in charge of a trans oceanic flight with a seriously flawed understanding of the consequences of leaving the wing tip tanks empty.

The ditching on 18 November 2009 was a consequence of deteriorating weather at Norfolk Island that was not forecast at the time of flight planning but was subsequently forecast and developed during the long flight. However, more effective flight planning, and application of a number of the existing regulatory and operator’s requirements before and during the flight would have better informed and prepared the flight crew for such contingencies. As it was, by the time that the crew comprehended the deteriorating weather at Norfolk Island they perceived that, given the available fuel and apparent lack of options, the safest avenue was to continue to Norfolk Island in the hope that they would be able to land safely.

Since when has ‘hoping’ to land safety at a destination after ignoring the fundamental requirement of airmanship to land immediately at the nearest alternative airport  in circumstances like those that were closing in on the inadequately fueled yet legal-in-Australia Pel-Air flight been an excuse for action that ends in a crash?

This is a severe reflection on CASA’s performance and that of Pel-Air, which is responsible in law for the performance and standards of its pilots  (as detailed in the CASA rules) and which has volunteered and enacted a set of safety improvements to prevent this happening again.

In its conclusions the ATSB repeats and elaborates on some criticisms of the pilots.


  • 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 report makes a number of important disclosures about differing pilot comprehensions about the rules that applied to the Pel-Air flight.

The ATSB report also details the results of an audit of Pel-Air’s operations that by coincidence had been scheduled for shortly after the accident and which have resulted in a large and comprehensive list of changes which can only leave the reader wondering what was going on in the operation prior to the accident.

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