Aug 30, 2012

Pel-Air ditching report hurts more as it sinks in

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 sa

Ben Sandilands — Editor of Plane Talking

Ben Sandilands

Editor of Plane Talking

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

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7 thoughts on “Pel-Air ditching report hurts more as it sinks in

  1. NeoTheFatCat

    I didn’t realise that the aircraft didn’t have sufficient fuel “to safely complete the flight in case of one engine inoperative or depressurised operations”, let alone divert to another airport. It really does sound like they used ‘hope’ as their main planning tool.

  2. Mark Newton

    Not taking anything away from the rest of your analysis, but characterising the weather as, “In darkness and in wild weather conditions,” is a bit over the top.

    We don’t have to guess: Page 55 of the report contains the automated weather observations for YSNF relevant to the time interval covered by the Pel-Air mission. The bottom of page 57 has the SPECI’s issued during and after the plane’s ditching, which indicate that the wind strength was between 6 and 9 knots.

    On the Beaufort Scale, 9 knots is Beaufort number 3 (“Gentle breeze”) and 6 knots is a 2 (“light breeze”). Under Beaufort force 3 conditions you’d expect wave heights to be 2 – 3 feet with possible foamy crests — not glassy, but not exactly good surfing weather either.

    The observations also include rainfall ranging between 0 and 0.4mm per 10 minute interval.

    The weather conditions were 19 degC, 100% humidity, low cloud and isolated showers with a gentle breeze, and weren’t deteriorating markedly between the arrival of the Westwind at the island and the rescue of the survivors. The weather related hazards weren’t “wild”; If they were, it’s quite possible that the luck that enabled them to return to dry land would have run out rather sooner than it did.

    There are more than enough failings chronicled in this report; exaggerating the weather is neither necessary, helpful or accurate.

    – mark

  3. Ben Sandilands


    I spoke to some of those on the flight and one involved in the rescue and it is possible that their descriptions of the conditions were unduly influenced by what they had experienced.

    I thought I’d made it clear that the deterioration in conditions referred to is that occurred en route as covered in meticulous detail in the report, and its discussion as to the reasons why the significance of those early warnings were not heeded until the alternative options had been exhausted.

  4. Mark Newton

    The observations starting on page 55 cover the entirety of the flight. They show the wind varying by a couple of knots, but the conditions at the flight’s end weren’t markedly worse than the conditions at the flight’s commencement except for the height and density of the cloud and the fact that it was dark and rainy.

    When the pilot submitted their flight plan at Apia, the METAR had 14 knot westerlies. By the time they got to YSNF it was 9 knot southerlies. If anything the “wildness” of the weather had actually improved 🙂

    The other local factor that I’ve heard bandied about a bit after this accident occurred is that the sea conditions at the jetty at Slaughter Bay are pretty terrible if there’s any southerly wind component, which there certainly was on the incident evening. So it’s entirely possible that the rescuers set out in sea conditions worse than they usually would, which were adequately manageable once they left the turbulence of the shore. Perhaps that’s what the rescuer you talked to was referring to?

    – mark

  5. Gary Currall

    Good to see that an armchair critic has added to the debate! Personally, I endorse Ben’s description – which although not forensically accurate certainly reflected my experience. Having first survived the impact and then almost drowning within the cabin, upon surfacing I had the distinct impression that the weather was wild and stormy. Of course I may have mistaken the “adequately manageable” sea conditions while being repeatedly slammed against the sinking fuselage with my lifejacket – less wife clinging desperately to my shoulder but I did have other, more pressing concerns – such as my hand – deeply cut by clinging to the torn wreckage and providing a rich burley trail in “shark infested waters”.

    By the way I’d like to apologise for the unhelpful exaggeration and hyperbole – maybe we should just stick to the inadequacies of the report and not shoot the messenger.

  6. discus

    Gary, thanks for posting your experience and hope all is now OK. Must have been extremely traumatic.

  7. Mark Newton

    Gary, thanks for joining in.

    I wouldn’t describe myself as a “critic,” and I’m certainly not shooting any messangers. I broadly agree with pretty much everything Ben has said about this case, except the one adjective he used to describe the weather, which is contradicted by the ATSB’s report.

    It must have been utterly terrifying for you and your wife, and the report makes it pretty clear that the pilots made decisions which set up a situation whereby your survival essentially came down to the luck of the draw, which is the exact opposite of what our safety regulatory system is supposed to deliver.

    – mark

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