Reopened investigation into 2009 aircraft ditching near Norfolk Island
The investigation team is now finalising the draft report and has started an internal review process. Once the internal review is completed, the report will be handed to the ATSB Commission for their consideration and approval. The ATSB will then provide the draft report to directly involved parties for their comment and feedback. Given the broad-ranging and complex nature of the investigation, and the size of the report, the draft report is now expected to be released to directly involved parties in early 2017.
The investigation process has required a cycle of continuing review of the evidence and the acquisition of new evidence as knowledge gaps and new lines of enquiry have been identified. Further, the ATSB has not sought to confine the scope of the reopened Norfolk Island investigation in the way that it normally would to manage its overall investigation outputs recognising the interests of all parties involved, as well as the Senate Inquiry and the Canadian Transportation Safety Board review of the original ATSB investigation.
A significant amount of detail is required to explain the findings, which are based on a rigorous application of the ATSB’s analysis methodology. To date, the investigation team has acquired and analysed an extensive range of evidence as part of the new investigation. This includes:
- reviewing evidence from the ATSB’s original investigation, and obtaining and reviewing evidence from CASA’s investigation of the accident, CASA’s special audit conducted soon after the accident
- recovering and analysing data from the aircraft’s flight recorders
- re-interviewing the flight crew and medical crew from the accident flight, and conducting over 30 additional interviews, including with 14 Pel-Air Westwind pilots, eight other Pel-Air personnel and six CASA personnel
- obtaining and analysing wind and temperature data, and integrating this information with Flight Data Recorder data, Cockpit Voice Recorder data, Air Traffic Control data, flight crew interviews and refuelling records to provide the best estimate of the aircraft’s fuel status during the accident flight
- obtaining and analysing 8 years of Westwind flight records from the operator’s fleet to examine fuel management aspects for different types of flights, particularly flights to remote aerodromes and air ambulance flights. This also involved obtaining and analysing meteorological information and other information for several flights
- obtaining and reviewing a substantial amount of documentation from the operator, including documentation from the operator’s safety management group meetings, selected samples of incident/hazard/fatigue reports, audit reports, flight crew training records for 18 Westwind pilots, and duty periods for all Westwind pilots for the 6 months prior to the accident
- obtaining and reviewing 10 years of CASA documentation associated with the operator’s Air Operator Certificates
- reviewing documentation from the air traffic services’ providers in Fiji and New Zealand about their policies and procedures for the provision of flight information, and how these were applied during the accident flight. Information was also obtained and analysed regarding how operations in Reduced Vertical Separation Minimum airspace were conducted.
The re-opened investigation has also involved many other activities, some of which have been outlined in the ATSB’s progress web updates.
The ATSB recognises the importance of being able to demonstrate that the reopened investigation addresses identified areas for improvement with the original investigation. Given the size of the report and the complexity of many of the issues, it is difficult to predict how long the draft review and final report processes will take, although it is likely to extend beyond those typical of more routine investigations/reports. After the draft report review process is complete, the ATSB should have a better understanding of a more specific likely timing for the release of the final report.