The point now, surely, is - how to make sure it doesn't happen
again.
I wonder if the ATSB report will conclude:
Safety Deficiencies:
The safety deficiencies identified relate to the accuracy of meteorological forecasts for Norfolk Island. The Bureau of Meteorology has advised that forecasts for remote Islands such as Norfolk are difficult to predict with accuracy and un-forecast conditions may occur without notice. Despite this advice the TAF issued at the commencement of the flight did not reflect this position.
Safety Recommendation:
Until the Bureau of Meteorology is confident of the accuracy of its forecasts for remote islands, a "PROB 20" line for constant conditions below the landing minima be added to
every forecast to warn pilots of the Bureau of Meteorology's position that these conditions may occur without notice.
Safety Deficiencies:
It is possible that this flight was planned without regard to the changes instigated after the
VH-TWR incident of 13 December 1999, which required alternate fuel for some operations to remote islands regardless of forecast. It is possible that the pilot in command was not aware of these requirements (or did not recall them at the time of pre-flight planning) as they are included in the CAOs, a different document to those usually referred to in pre-flight planning for normal operations. It is possible, that the PIC (as a PIC would for a mainland operation) simply compared the forecast conditions with the
Alternate Minima listed on the Norfolk Is. approach chart.
Safety Recommendation:
The
Alternate Minima section of all approach charts for all remote island destinations be amended to include a note that an alternate is required, regardless of forecast, for passenger carrying CHTR and RPT operations.