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#PelAir Investigation re-opened

 PelAir Investigation re-opened:

The pressure from the Senate inquiry, the Canadian TSB [summarised by Paul Phelan]  has resulted in the re-opening of ATSB process [outlined below]. The Senate estimates of Tuesday 24th February 2015 reveal that the re-investigation will only involve ATSB personnel.

Heavy questioning by Senator Xenophon went to why only ATSB [according to Dolan] could re-investigate. Dolan says – Our Act does not allow this!!

Question is – What of ICAO Annex 13, which is the basis for the investigation anyway. This [Annex 13] allows for other [non-compromised] organisations to be used or briefed. The cynical thoughts certainly may arise here, as again it is the investigator investigating the investigator.

And with such a small organisation [now < 100 people] how can the previous investigations be kept away from the new investigations?? Just removing the old report from the site is not enough.

A repcon was recently raised by industry on how ATSB is not properly conveying safety matters to industry

and is worth a re-read.

The two reports by ATSB on #pelair are below:

  1. Preliminary;
  2. Final report


From the ATSB web-site:

Aviation safety investigations & reports

Investigation title

Ditching of Israel Aircraft Westwind 1124A aircraft, VH-NGA, 5 km SW of Norfolk Island Airport on 18 November 2009

Investigation number: AO-2009-072
Investigation status: Active

What happened

On 18 November 2009, the flight crew of an Israel Aircraft Industries Westwind 1124A aircraft, registered VH-NGA, was attempting a night approach and landing at Norfolk Island on an aeromedical flight from Apia, Samoa. On board were the pilot in command and copilot, and a doctor, nurse, patient and one passenger.

On arrival, weather conditions prevented the crew from seeing the runway or its visual aids and therefore from landing. The pilot in command elected to ditch the aircraft in the sea before the aircraft’s fuel was exhausted. The aircraft broke in two after ditching. All the occupants escaped from the aircraft and were rescued by boat.

Updated: 18 February 2015

On  4 December 2014, the Australian Transport Safety Bureau (ATSB) formally re-opened investigation AO-2009-072 into the ditching of an Israeli Aircraft Industries Westwind 1124A, registered VH-NGA, which occurred 5 km south-west of Norfolk Island Airport on 18 November 2009. The action to reopen the investigation was taken by the ATSB Commission in response to the recently-released peer review, by the Transportation Safety Board (TSB) of Canada, of the ATSB’s investigation methodologies and their general application including in investigation AO-2009-072. The TSB review highlighted how ATSB methodologies could have been better applied in investigation AO-2009-072 to meet the expectations of the aviation industry and the public.

The re-opened investigation will review the evidence obtained during the original ATSB investigation, and the report of that investigation, in the light of any additional evidence and other relevant points raised in the TSB review and separate reviews by the Senate Rural and Regional Affairs and Transport References Committee and through the Deputy Prime Minister’s Aviation Safety Regulation Review. The main focus will be ensuring that the specific findings of the TSB review are taken fully into account before issuing a final report of the re-opened investigation.

The re-opened investigation will in particular be examining:

  • pre-flight planning and fuel management procedures and practices
  • in-flight fuel management and related decision-making procedures and practices
  • fatigue management procedures and practices
  • flight crew check and training
  • the operator’s oversight of its flight operations activities
  • provision of weather and other flight information to flight crews
  • cabin safety and survival factors
  • regulatory oversight of activities such as those listed above.

The re-opened investigation has already requested a substantial amount of additional documentation from the operator, the Civil Aviation Safety Authority (CASA) and other parties. After reviewing the existing evidence and additional documentation, the investigation team will also be seeking to interview a number of personnel from the operator, CASA and other organisations, as well as re-interviewing occupants of the accident aircraft. In addition, the ATSB will take all reasonable steps to recover the flight recorders from the accident aircraft and download and analyse the data from them.

The re-opened investigation is being conducted by an experienced team of ATSB investigators who have expertise in flight operations, human factors, organisational factors, air traffic control and cabin safety, and who were not part of the original investigation team. Oversight of the investigation team and lines of reporting to the ATSB Commissioners for the re-opened investigation have also been changed from the original investigation.

The draft report from the re-opened investigation will be sent to Directly Involved Parties for feedback before being publicly released, in line with the ATSB’s normal processes.

The re-opened investigation is in its early stages. Given the level of work involved, it is expected to take 8 to 12 months to complete. In parallel, the previously issued final report of the investigation has been removed from the ATSB website until the re-opened investigation is complete. If any new safety issues are identified during the investigation, these will be communicated to the relevant parties as soon as possible.

General details

Date: 18 Nov 2009 Investigation status: Active
Time: 1026 UTC Investigation type: Occurrence Investigation
Location   (show map): 5 km SW of Norfolk Island Airport Occurrence type: Aircraft preparation
State: External Territory Occurrence class: Operational
Release date: 18 Feb 2015 Occurrence category: Accident
Report status: Pending Highest injury level: Serious
Expected completion: Dec 2015

Aircraft details

Aircraft manufacturer: Israel Aircraft Industries Ltd
Aircraft model: Westwind 1124A
Aircraft registration: VH-NGA
Serial number: 387
Type of operation: Aerial Work
Sector: Jet
Damage to aircraft: Serious
Departure point: Apia, Samoa
Departure time: 0545 UTC
Destination: Norfolk Island

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