Accident IAI 1124A Westwind II VH-NGA,

ASN Wikibase Occurrence # 321402

Date:	Wednesday 18 November 2009
Time:	21:56
Type:	IAI 1124A Westwind II
Owner/operator:	Pel-Air
Registration:	VH-NGA
MSN:	387
Year of manufacture:	1983
Total airframe hrs:	21528 hours
Cycles:	11867 flights
Engine model:	Garrett TFE731-3-1G
Fatalities:	Fatalities: 0 / Occupants: 6
Aircraft damage:	Substantial, written off
Category:	Accident
Location:	5 km SW off Norfolk Island Airport (NLK) - Norfolk Island
Phase:	Landing
Nature:	Ambulance
Departure airport:	Apia-Faleolo Airport (APW/NSFA)
Destination airport:	Norfolk Island Airport (NLK/YSNF)
Investigating agency:	ATSB
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
An IAI 1124A Westwind II jet, registered VH-NGA and operating under the instrument flight rules (IFR), was ditched 3 km south-west of Headstone Point, Norfolk Island after a flight from Apia-Faleolo Airport (APW). The two flight crew, doctor, flight nurse, patient and one passenger all escaped from the ditched aircraft and were rescued by boat crews from Norfolk Island.
On 17 November 2009, the airplane an aeromedical retrieval operation from Sydney, NSW, Australia to Samoa with an en route stop at Norfolk Island.
The next day the flight was to return to Norfolk Island and then to continue to Melbourne. Departure time from Samoa was 05:45 UTC, and the plane initially climbed to a cruising altitude of FL350 and later to FL390. En route the 80 kts headwind was greater than expected, resulting in a revised ETA of 09:30 UTC, 30 minutes later than planned.
During the flight the crew were advised of deteriorating weather conditions at Norfolk Island. The crew had increasing concerns about their fuel reserves. The crew later indicated that the higher-than-expected en route winds, and not knowing the winds for an off-track diversion, reinforced their doubt. The crew stated that they decided to continue to Norfolk Island because, on the basis of the observed weather conditions at the island being above the landing minima, they expected to be able to land safely. They believed that action was safer than a longer off-track diversion to Noumea, with at that stage unknown destination weather and marginal fuel remaining.
At 09:28, when about 160 NM (296 km) from Norfolk Island, the flight crew was advised by the airports Unicom operator about the presence of Broken cloud at 300 ft, 800 ft and 1,100 ft above the airport and visibility 6,000 m. That was, the observed weather was below the landing minima.
The copilot planned to conduct a runway 29 VOR/DME instrument approach. The crew reported agreeing that the expected weather would mean that visual reference with the runway may be difficult to obtain, and that the pilot-in-command (PIC) would closely monitor the approach by the copilot. During the briefing for the first approach, the crew agreed that, if visual reference with the runway was not obtained, the PIC would take over control of the aircraft for any subsequent approaches.
The Unicom operator contacted the crew again at 09:38 and stated that the weather conditions had deteriorated because a rainstorm was 'going through'.
The flight crew initiated a missed approach procedure from the first approach at 10:04:30. The flight crew reported that the PIC then assumed control of the aircraft as agreed during the pre-descent briefing. At 10:13, the flight crew initiated a second missed approach for runway 29 as they did not obtain the required visual references before the missed approach point.
The flight crew then elected to conduct a VOR approach to runway 11 (in the opposite direction) to take advantage of the lower landing minima for that approach. The runway 11 VOR permitted the aircraft to be flown to 429 ft above the runway threshold and to continue for a landing with a visibility of 3,000 m; however, there was a tailwind of up to 10 kts for operations to runway 11. The crew did not obtain the required visual references from the approach and initiated a missed approach procedure at 10:19.
At this time, the flight crew decided that they would ditch the aircraft in the sea before the fuel was exhausted. The copilot briefed the doctor and the passenger who was sitting in the front left cabin seat to prepare for a ditching. At 10:19, the crew reported to the Unicom operator that "were going to have to ditch we have no fuel".
The flight crew decided to conduct one more instrument approach for runway 29 as, if they did not become visual off that approach, the missed approach procedure track of 273 °(M)would take the aircraft to the west of Norfolk Island, over open sea and clear of any obstacles for the planned ditching.
The PIC reported descending the aircraft to a lower height than the normal minimum descent altitude for the runway 29 VOR approach procedure in a last attempt to become visual. The crew did not become visual and at 10:25 the PIC made a fourth missed approach and the Unicom operator was notified that they were "...going to proceed with the ditching".
The airplane was configured for landing, without extending the landing gear, and was ditched off shore.

On 4 December 2014, the ATSB formally reopened the investigation following a parliamentary inquiry.
On 11 November 2015, the rear section of the aircraft which contained the flight recorders, was salvaged and both recorders were recovered.

CONTRIBUTING SAFETY FACTORS:
- 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 flight crews delayed awareness of the deteriorating weather at Norfolk Island combined with incomplete flight planning to influence the decision to continue to the island, rather than divert to a suitable alternate.

Accident investigation: