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Table Of Contents

THE AUSTRALIAN TRANSPORT SAFETY BUREAU
TERMINOLOGY USED IN THIS REPORT
FACTUAL INFORMATION
History of the flight
Positioning flight to Samoa
Return flight
Injuries to persons
Damage to the aircraft
Personnel information
Pilot in command
Copilot
General
Aircraft information
Fuel system
Meteorological information
Norfolk Island weather products
Aids to navigation
Communications
Aerodrome information
Flight recorders
Wreckage and impact information
Medical and pathological information
Survival aspects
Ditching
Search and rescue
Locator beacons
Organisational and management information
Regulatory context for the flight
Operator requirements
Application of the pilot’s assumed weather conditions to the flight
The decision to continue to Norfolk Island
Support information available to flight crew
Threat and error management
Aeromedical organisation consideration of operator risk
ANALYSIS
Introduction
Operational guidance and oversight
Pre-flight planning
Flight plan preparation and submission
Implications for the flight
En route management of the flight
Seeking and applying appropriate en route weather updates
Exit from the aircraft and subsequent rescue
Conclusion
FINDINGS
Contributing safety factors
Other safety factors
Other key findings
SAFETY ACTION
Civil Aviation Safety Authority
Fuel planning and en route decision-making
Aircraft operator
Oversight of the flight and its planning
Aeromedical organisation
Consideration of operator risk
APPENDIX B: WEATHER INFORMATION AT NORFOLK ISLAND
Meteorological report
Meteorological forecast
Norfolk Island aerodrome weather reports and forecasts
Weather observations/reports
Aerodrome forecasts (TAFs)
Sequence of meteorological events at Norfolk Island Airport
APPENDIX C: SOURCES AND SUBMISSIONS
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Pel Air Accident Report

Pel Air Accident Report

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Published by Pat Byrne
Example of a very poor accident report carried out by the ATSB
Example of a very poor accident report carried out by the ATSB

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Published by: Pat Byrne on Nov 28, 2013
Copyright:Attribution Non-commercial

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01/14/2014

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