On the 18th November 2009, a Pel-Air jet on a CareFlight mission took off from Apia airport in Samoa. Its destination was Norfolk Island, and then on to Melbourne. There were six people on board, including a patient with a serious medical condition. As they prepared to leave Samoa, the pilot was told the weather ahead was fine and planned his trip accordingly. But the aircraft never made it to its destination. Instead, caught in a brutal storm, the pilot ditched the plane at sea, in shark-infested waters. Miraculously, all six people on board survived.

Back on land, the Pel-Air Chairman told the media that the pilot - Dominic James - was a hero. A month later, the Civil Aviation Authority (CASA) took away James' pilot licence and his reputation was all but destroyed. Now Four Corners talks to the people on board and those involved in the flight, investigating what really happened that fateful night and in the hours leading up to the crash. Who really was at fault, and could the crash have been avoided?

"Crash Landing", reported by Geoff Thompson and presented by Kerry O'Brien, goes to air on Monday 3rd September at 8.30pm on ABC1. It is replayed on Tuesday 4th September at 11.35pm. It can also be seen on ABC News 24 on Saturday at 8.00pm, on ABC iview or at abc.net.au/4corners.

Transcript

"CRASH LANDING" Broadcast 3 September 2012

KERRY O'BRIEN, PRESENTER: A Pel-Air jet on an air ambulance mission, down in stormy seas.

KAREN CASEY, CAREFLIGHT NURSE: The jet cracked in half exactly where I was sitting.

BERNIE CURRALL, CRASH SURVIVOR: You don't know what was going to happen to you. You're convinced you're going to die.

KERRY O'BRIEN: The crash was horrific, even though everyone survived, but for the pilot it was far from over.

DOMINIC JAMES, PILOT: I was pretty traumatised by what had happened that night and in the water, but it was nothing compared to the trauma I suffered at the hands of CASA when they came after me.

KERRY O'BRIEN: But first he was a hero, then he was cast as the villain. But has this pilot become a scapegoat?

Welcome to Four Corners.

In the history aviation there is just one recorded incident that we can find where a pilot has ditched a jet at night, in the ocean and everyone on board has survived. It happened in November 2009 off the coast of Norfolk Island, and the pilot that night was Dominic James.

Initially, he was hailed as a hero, but a short time later the Civil Aviation Safety Authority, CASA, took his licence away and blamed him for the crash. For three years now that has been the public version of events. Now, the Australian Transport Safety Bureau, the ATSB, has released its findings on the crash, singling out the pilot once again. Saying he had not planned the flight according to the book.

But Four Corners has information suggesting responsibility does not stop with Dominic James.

Tonight's story will reveal the contents of a CASA special audit, finalised just weeks after the crash which contains strong criticisms of the company Pel-Air that operated the Westwind jet that James was flying that night. It has never been released to the public.

Tonight, we trace that flight across the Pacific, moment by dramatic moment, from the perspectives of crew, passengers and rescuers. But we also seriously question the transparency of the subsequent investigation undertaken by the nation's air safety regulator, CASA, and also the Australian Transport Safety Bureau, the bodies sworn to get to the truth of any civil aviation crash.

The reporter is Geoff Thomson.

(Reconstruction plays throughout)

GEOFF THOMSON, REPORTER: Apia airport, Samoa.

It's the 18th of November 2009 and the flight crew of Westwind jet, VH-NGA, are preparing for a medical evacuation to Australia.

They plan to stop at Norfolk Island to refuel.

DOMINIC JAMES: I got the forecast for Norfolk, which was for good conditions, excellent conditions actually.

GEOFF THOMSON: Confident of fine weather on Norfolk, Captain Dominic James fills his main tanks, but not the tip tanks on the aircraft's wings.

As the sun sets there are unwelcome delays.

DOMINIC JAMES: The transport from the hotel was held up and I then assisted with loading the patient onboard the aircraft.

BERNIE CURRALL: I just wanted to see my family, you know, like I'd just been to hell and back on the operating table.

GEOFF THOMSON: After a botched hysterectomy became infected Bernie Currall is now in Australian medical care and going home with her husband Gary.

GARY CURRALL: We were very confident, from that point on. Very confident, things were going to go well.

GEOFF THOMSON: Karen Casey loves her job as a CareFlight nurse.

KAREN CASEY: The C to the A to the R to the E to F to the L to I to the G...

UNIDENTIFIED MALE: Forgot the H but that's all right.

GEOFF THOMSON: But she's only on this trip because she's volunteered to cover for a friend.

It's Dr David Helm's first trip to Samoa.

DR DAVID HELM, CRASH SURVIVOR: I've always been a great fan of aviation. You know some would say a bit of a thrill seeker, so I was just looking for a bit of a change.

BERNIE CURRALL: They were just gonna fly me home. They were gonna just put me in a hospital in Melbourne or Sydney, I can't remember. And they were just gonna fix me up and I was just gonna toddle off a few days later.

GEOFF THOMSON: With six people safely on board, they take off from Samoa just before dark.

Captain Dominic James had flown patients to Australia from islands in the South Pacific about 50 times in the two years he'd been a Medevac pilot.

His co-pilot was Zoe Cupit.

DOMINIC JAMES: We went to these extraordinary destinations and places that aren't normally visited by a corporate jet. And then we had to race them back to Australia as quick as possible to make sure they had the best chance of survival.

(Reconstruction plays)

GEOFF THOMSON: They plan for a three-and-a-half -hour flight to Norfolk Island.

Strapped in, Bernie Currall falls asleep.

GARRY CURRALL, CRASH SURVIVOR: I took my laptop out. I read a book. Yeah, I just generally relaxed.

GEOFF THOMSON: The jet would pass through airspace controlled by New Zealand, then Fiji, and New Zealand again as it nears Norfolk Island.

Until then, all communications about weather would be via low quality HF radio.

KAREN CASEY: We had a very, very long day. So David and I agreed that I would have a bit of a snooze from Samoa to Norfolk. And then David was going to snooze from Norfolk to Melbourne. We were able to do that because of Bernie's stability.

GEOFF THOMSON: About 250 kilometres from Norfolk Island the Westwind begins its descent.

KAREN CASEY: David sort of shook me and he said we're about to start our descent. So I sat up and we tightened Bernie's belts.

DR DAVID HELM: There's always that sort clunk as the wingtip lights come on, the landing lights, and then a sort of grinding sound as the landing gear came down.

GARY CURRALL: We were obviously descending. It got quite rough at that stage and I could feel us being buffeted about. And again I consider that nothing unusual in a, in a small aircraft.

GEOFF THOMSON: Norfolk Island has no air traffic controller.

Instead it has a radio operator known as a Unicom.

That night it is manned by Larry Quintal.

LARRY QUINTAL, NORFOLK ISLAND UNICOM OPERATOR: When I signed on to the airport that night I knew then that the situation wasn't, you know, ideal for any aircraft to fly into Norfolk Island.

(Excerpt from VHF radio communication on the night of the crash)

DOMINIC JAMES: Norfolk Radio this is Victor-Hotel-November-Gulf-Alpha do you copy?

LARRY QUINTAL: Victor-Hotel-November-Golf-Alpha good evening to you sir, go ahead?

GEOFF THOMSON: These are actual recordings of Larry's conversations with the flight crew.

(Excerpt from VHF radio communication on the night of the crash)

DOMINIC JAMES: We're about a bit over 20 minutes from you.

(End excerpt)

(Four Corners): Once we're on the short-range VHF radio and I was speaking to Larry, who I trusted, and he'd said the conditions were bad, that's when I became quite concerned about what was going to take place.

(Excerpt from VHF radio communication on the night of the crash)

(VHF Radio Communication): I just wanted to get an appreciation about weather. It doesn't sound great but you guys would know better than the robot weather would.

LARRY QUINTAL: November-Golf-Alpha, mate, it has just deteriorated a bit as we speak.

(End excerpt)

GEOFF THOMSON: Dominic James asks Larry Quintal to go out on the runway and judge the weather for himself rather than rely on reports from an automated system.

(Excerpt from VHF radio communication on the night of the crash)

LARRY QUINTAL: Evening guys. Look I've just come back out from on the runways there. We do have a rain cell that's hitting the runway at this time, the airport. Visibility has dropped down to around about 4,000 as we speak but I think it's all because of this rain storm we've got coming through here now.

DOMINIC JAMES: Okey dokes, well keep me posted of any developments thanks and I'll speak to you shortly.

LARRY QUINTAL: Copy that. I'll keep you informed of the cloud base as we go along. And have you got an alternate for this evening?

DOMINIC JAMES: Negative, we don't.

(End excerpt)

KAREN CASEY: David had a map of Norfolk Island in his hand and I said to him we'll probably divert to Noumea, and he was like 'yeah'. He says 'that's probably like the closest'. I said, 'yeah'.

GEOFF THOMSON: Flight VH-NGA has not planned for an alternate destination, and by now is past the point of no return.

Norfolk Island has the only runway within reach.

Suddenly there is a break in the weather.

(Excerpt from VHF radio communication on the night of the crash)

LARRY QUINTAL: November-Golf-Alpha, Norfolk, the showers have sort of abated a bit here. Copy all?

DOMINIC JAMES: I did indeed. Great news, thank you very much. Keep me posted.

GEOFF THOMSON: Co-pilot Zoe Cupit makes the first approach.

DOMINIC JAMES: With the landing lights on that were fitted to each wing tip of that jet, that were very, very bright, you could very easily see just how heavy the rain was and how heavy the cloud was.

KAREN CASEY: We went for the first approach and I felt the aircraft ascend and the engines become louder. So I thought oh it's OK, it's a missed approach. That's happened before, that's OK.

GEOFF THOMSON: Dominic James then takes the controls for another attempt.

DOMINIC JAMES: But again, we got to the missed approach point and we never saw any part of the runway or the ground.

KAREN CASEY: Then we went tried again and I thought 'oh that's strange, that's really strange, haven't had two missed approaches before.'

GARY CURRALL: This happened on two or three more occasions, and the atmosphere in the cabin was getting increasingly concerned I guess you'd say.

DOMINIC JAMES: I realised we had a huge problem in front of us.

GEOFF THOMSON: But nothing had prepared Larry Quintal for what he would hear next.

(Excerpt from VHF radio communication on the night of the crash)

DOMINIC JAMES: Norfolk, we're going to have to ditch, we've got no fuel.

LARRY QUINTAL: November-Golf-Alpha are you serious?

(End excerpt)

DOMINIC JAMES: I was most concerned that in the event the engines flamed out that the aircraft would start gliding in a fashion that is extremely difficult to control.

GEOFF THOMSON: Co-pilot Zoe Cupit convinces Dominic James to give it one more go.

(Excerpt from VHF radio communication on the night of the crash)

ZOE CUPIT, CO-PILOT: November-Golf,-Alpha, we'll come around again. Give us the current conditions please?

LARRY QUINTAL: Cloud base at this time is broken at 200, broken at 700. Visibility at 2,700. The visibility has deteriorated.

KAREN CASEY: That's when I knew that something was really wrong. My legs started to turn to jelly.

GARY CURRALL: The cockpit door got slid open and Zoe looked back at me with a look of pure horror and said 'we're going to ditch.'

KAREN CASEY: And I felt that feeling that you have in your stomach when you know something's really bad's going to happen. It's, I suppose it's the feeling of doom.

BERNIE CURRALL: Karen was really like looking at me, and you know she was scared.

(Excerpt from VHF radio communication on the night of the crash)

LARRY QUINTAL: November-Golf-Alpha, Norfolk, can you talk yet?

ZOE CUPIT: Nup.

(End excerpt)

GEOFF THOMSON: Larry Quintal is given no information indicating just where the jet is likely to ditch.

LARRY QUINTAL: When I listened to the radio I was waiting for them to give me some sort of coordinates or the direction or their compass or their speeds, anything, anything at all you know?

(Excerpt from VHF radio communication on the night of the crash)

ZOE CUPIT: We're going to proceed with the ditching

LARRY QUINTAL: OK I'm going to put everybody on alert.

(End excerpt)

DOMINIC JAMES: We turned the aircraft to the left and proceeded to the southwest of the island. And watching the weather radar on the screen and watching the ground returns from that radar, once I was sure that we were over the water I then gently let the aircraft down towards the ocean.

FLIGHT COMPUTER: Terrain, terrain, pull up, pull up.

KAREN CASEY: We made sure that everything in the cabin was secured. I really hoped that I would die very quickly, 'cause I didn't think there was a miniscule of hope.

GARY CURRALL: The doctor then jumped in and said 'Gary, you'll need to put this on'- handed me a life jacket.

BERNIE CURRALL: I just remember looking over at Gary and saying 'but Gary I don't have a life jacket.'

GARY CURRALL: And during that whole sequence not once did it occur to me to check on anybody else. Bernie, my wife.... (breaks down) Sorry.

BERNIE CURRALL: We were holding hands 'cause I'm lyin' down, he's across there; and then the doctor told us 'Gary, brace position'.

(Reconstruction of landing plays)

GEOFF THOMSON: As he prepares to ditch in a raging sea on the blackest of nights with little hope of survival Dominic James focuses on his instruments.

FLIGHT COMPUTER: Pull up, pull up, pull up.

DOMINIC JAMES: I slowed the aircraft down to the slowest possible speed I dared. I then reduced the descent rate down to as little as possible.

DR DAVID HELM: I felt the flare of the plane and I felt the engines throttle back, and that slight momentary sort of peace really of just the glide.

LARRY QUINTAL: And I listened to the radio and then all I can hear is just a little 'psssttt'. And I knew in my heart they've gone.

BERNIE CURRALL: Hitting the water, it was like a bomb exploded.

(Reconstruction of crash plays)

GEOFF THOMSON: The jet splits in two under Karen's seat.

KAREN CASEY: I felt it. I felt it, I felt it run through my body. I was absolutely shocked to the core.

GARY CURRALL: Half expected that the plane would somersault at that point or cartwheel or something.

GEOFF THOMSON: But it doesn't.

Somehow the Westwind stays level and crashes through the heavy swell.

KAREN CASEY: The jet cracked in half exactly where I was sitting and the water spurt in from the sides immediately.

(Reconstruction of passengers and crew in the sinking jet)

BERNIE CURRALL: And the next thing I'm under water.

KAREN CASEY: And the water was gushing in over Bernie's face because that's where the emergency exit is.

BERNIE CURRALL: I was powerless, I was powerless. I had no control.

GEOFF THOMSON: As the cabin fills with water, every second counts.

DR DAVE HELM: I think that's hardest bit for me, 'cause at that moment, I knew I'd undone some belts but I didn't know if I'd undone enough.

KAREN CASEY: David dragged her out. But before he dragged her out I recall yelling out to David that I couldn't get my belt off.

GARY CURRALL: I started gasping for breath, inhaling water and choking. I got hit by a wave that hit me the chest and from the rear and then propelled me into the ceiling.

KAREN CASEY: I put my hands down on my belt and felt where it was twisted and ran my fingers across and untwisted it and I got the belt off. And I had to swim through the fuselage.

DOMINIC JAMES: I opened the exit, and with water gushing in through the exit, I went through it.

I surfaced and immediately I called out and had someone call back.

(Reconstruction of everyone in the water after escaping the jet)

GARY CURRALL: When we got to the surface it was chaos. The sea was raging, the wind was blowing, I couldn't take a breath.

DOMINIC JAMES: We did a roll call and we were all there. I got five answers back, which I wasn't expecting.

GARY CURRALL: It seems as if he was always circling us, but swimming without a life jacket. Always trying to keep us together, always keeping us pointed towards the island.

GEOFF THOMSON: Only three of the six survivors are wearing life jackets.

(Reconstruction of rescue operation getting underway on Norfolk Island)

Back on Norfolk Island a rescue operation is mobilised.

GLENN ROBINSON: I got down to the jetty and there was just not another soul there. And sitting on the end of the pier and looking out to sea knowing that somewhere out there, there was an aircraft in the water and six people on board it. Not really knowing what was going on out there, it was, it was just an awful feeling.

GEOFF THOMSON: Skipper Darren Bates and his crew winch his boat off Kingston Pier ready to navigate a narrow reef channel out to sea.

It's hard to do even in daylight.

DARREN BATES, SKIPPER: It was all dark and pretty foggy and drizzly and we lowered the boat in the water using the local crane that's down there.

GEOFF THOMSON: With paramedics now on board Darren Bates heads out into the heavy swell.

No-one on the island has any idea where they ditched.

(Reconstruction of rescue boat heading out)

LARRY QUINTAL: When the boats launched I actually said to them at the time, this is the area you will have to concentrate on to the south. Believing in my heart that was their final direction they were heading.

GEOFF THOMSON: With no plane crash on the island, local firefighter Scott Greenwood has been told to go home.

SCOTT GREENWOOD, FIREFIGHTER: I left the station and thought 'well I'm not going home, 'cause there's six people out there fighting for their life somewhere'. So I thought 'maybe he's ditched off the western end of the Island'.

(Reconstruction of Dominic James in the water)

GEOFF THOMSON: Swimming without a life vest, Dominic James brushes against a small LED (Light-Emitting Diode) torch in his shirt pocket.

DOMINIC JAMES: And to my surprise I reached for it and turned it on and realised it still worked very well. It was incredibly bright for such a small torch.

KAREN CASEY: He yelled out to us that he's found the torch, and we're all just praying that it worked.

GARY CURRALL: He propelled himself up by obviously kicking his legs, and directing the torch towards the island and flickering it backwards and forwards. Yeah, that was - that's quite a clear memory.

(Reconstruction of Scott Greenwood in his car)

SCOTT GREENWOOD: Turned my lights off and straight away I saw this faint glow and I wasn't sure whether it was just my eyes tricking me or - it was that faint.

GEOFF THOMSON: There is no moon that night. Only blackness.

SCOTT GREENWOOD: I got out of the car and let my eyes adjust a bit more, and sure enough, there was definitely something out there that I could see every now and then. Just a little greenish light.

GARY CURRALL: We might have flickered that torch all night long but if somebody hadn't have been there to see it, what would have been the use.

GEOFF THOMSON: Scott Greenwood reports what he's seen.

SCOTT GREENWOOD (reconstruction): Yeah there's something out the west here.

GLENN ROBINSON: Somebody's called in and said that they thought they saw some lights off to the west.' And I was like 'oh well, you beauty, we'll take that because we've got nothing else to go on'.

DARREN BATES: So we pointed the boat in a westerly direction and steamed that way for, I guess, 10 minutes, while I got the radar up and running. There was one particular blip there that kept coming up, and we just set auto-pilot straight for that, expecting it to be a wreckage or something.

KAREN CASEY: That was at that point that I saw the green light to my right.

(Reconstruction of rescue)

GARY CURRALL: We'd been through this before and light reflections off the water had turned out not to be a boat. But it didn't seem worth getting our hopes up and all of a sudden it was there, there was a boat.

AARON GRAHAM, DECKHAND (reconstruction): I can see four, four lights

GEOFF THOMSON: Deckhand Aaron Graham spots lights in the water.

Dim lights on life vests.

DARREN BATES: The we got closer and closer and then, all of a sudden, got the spotlight on and there were these people in the water. It was just so exciting when we saw these people were alive, and arms going like this (waves arms above his head).

GLENN ROBINSON: It gives me goose bumps still, thinking about it, recalling that, that there's six of them in the water. They were all alive, you know, they've ditched a jet plane into a rolling ocean in the middle of the night and here they are. It's just incredible, it really was.

AARON GRAHAM (Reconstruction): Roll over ..

BERNIE CURRALL: You turn round and there was this big boat with all these lovely big fellas in it. I can't describe the relief, I just can't, you know.

GARY CURRALL: These guys just bodily picked us out of the water, you know. It was it was quite amazing.

BERNIE CURRALL: I was in the nude, everything had gone. I don't know why, I don't know how.

GARY CURRALL: Bernie went first. I remember one of them shouting down, 'this one's naked!' And in the middle of the South Pacific after what we'd just been through it just seemed a moment of humour. Why is this one naked? (laughs).

GEOFF THOMSON: Ninety minutes after crashing into the sea, they are rescued.

(Reconstruction of survivors on Darren Bates' boat)

MEDIC (reconstruction): I'm just going to roll you to the side.

GEOFF THOMSON: Skipper Darren Bates faces the still challenging task of safely winching his boat and all the survivors ashore.

DOMINIC JAMES: Once we got level with the wharf, I realised there was quite a lot of people on that wharf and everyone started cheering. And we knew we'd made it. It was a very strange night, a very strange feeling.

(Reconstruction of survivors arriving ashore at Norfolk Island)

GEOFF THOMPSON: What happened here had never happened before. All the occupants of a jet ditched in the middle of the night in an open and angry ocean walked away alive.

But it was just the beginning of a drawn-out ordeal for the flight crew and the passengers as the questions began; asking just who were the heroes and who was at fault on that fateful Norfolk night.

GEOFF THOMSON: Captain Dominic James returns to the mainland lauded as a hero by his company and the media.

NEWS PRESENTER (Sky News, November 2009): All those on board were taken to the hospital once they'd reached the island, all owing their lives to one very brave pilot.

(Photograph of Dominic James in Cleo Bachelor of the Year spread)

GEOFF THOMSON: The media latches onto the pilot's minor celebrity status as a Cleo bachelor of that year.

DOMINIC JAMES: I wish I'd never done it. I was embarrassed. It was hugely inappropriate for that picture to exist of me and the circumstance that I now found myself in.

GEOFF THOMSON: Former federal transport minister and now Pel-Air chairman, John Sharp, praises his pilot.

JOHN SHARP, CHAIRMAN, PEL-AIR (November 2009): Well if he wasn't a hero before I suspect he's becoming one. What he has been able to perform with the assistance of the co-pilot is an outstanding achievement. I mean in aviation terms this is right at the gold medal level.

(Footage of Dominic James' Westwind jet on the ocean floor is shown)

GEOFF THOMSON: But immediately after the incident Pel-Air grounded its fleet of Westwind jets.

The company then came under scrutiny by Australia's aviation regulator the Civil Aviation Safety Authority: CASA.

JOHN MCCORMICK, DIRECTOR SAFETY, CASA: We worked with the Pel-Air management who were very proactive to ensure that the Pel-Air operation was safe.

GEOFF THOMSON: At the same time an investigation into the ditching itself was launched by the Australian Transport Safety Bureau: the ATSB.

MARTIN DOLAN, ATSB CHIEF COMMISSIONER: We get ourselves an investigation team together as quickly as possible and despatch them to wherever they need to go and the process starts from there.

GEOFF THOMSON: CASA's first action was to suspend the pilot's licences.

DOMINIC JAMES: Christmas Eve, late Christmas Eve, I got an email that I wasn't expecting from CASA saying they've suspended my licence. And I was devastated. I was completely ashamed. I never in my wildest nightmare thought that I'd ever have my licence suspended.

GEOFF THOMSON: CASA based its suspension on the pilot's failure to plan the flight correctly.

It said he failed to take enough fuel and ignored weather warnings.

BRYAN AHERNE, AVIATION SAFETY INVESTIGATOR (to Mick Quinn): Have we got the fade (phonetic) score on Zoe?

MICK QUINN, FORMER DEPUTY CHIEF OF OPERATIONS, CASA: No I haven't seen it.

GEOFF THOMSON: Mick Quinn is a former deputy chief of operations at CASA.

Bryan Aherne has worked for both CASA and the ATSB.

They believe CASA and the ATSB have unfairly focussed on Dominic James.

MICK QUINN: There were a lot of things that lined up here in various organisations on the day and unfortunately he just happened to be the person who was sitting there. This could happen again to someone else.

GEOFF THOMPSON: Almost three years after the ditching the Australian Transport Safety Bureau finally released its report last week.

The ATSB prides itself on being a 'no blame' investigator.

But its findings make it very clear that responsibility for the ditching rests primarily with the flight crew.

But there's a document which the Australian public was never meant to see.

It's CASA's special audit of Pel-Air, completed just after the ditching in 2009

It identifies significant deficiencies within the company's Westwind operations in Pel-Air.

What it describes sounds like an accident waiting to happen.

It lists numerous breaches of aviation regulations and legislation covering fuel policy, flight planning and pilot training.

JOHN MCCORMICK: None of those, 31 I think it is, requests for corrective action that we found when we did the in-depth audit of Pel-Air would've affected that accident or prevented that accident.

GEOFF THOMPSON: But given that the operator was failing in areas of fuel planning, fatigue, check and training, lack of support for pilots, and these were regulatory breaches, isn't that something the Australian public has the right to know about, given that that's what the operator was doing when this ditching occurred?

JOHN MCCORMICK: Well as I say, none of those particular incidents or events that we looked at within that audit would've prevented that accident. The accident was caused by poor fuel planning, poor decision making.

GEOFF THOMSON: Dominic James has his own view about why these breaches have been kept secret.

DOMINIC JAMES: I think all the embarrassing questions that were going to come from going after Pel-Air were best left alone. And I think that the most convenient and appropriate way in their minds forward was to go after me. It solved a lot of problems for them.

GEOFF THOMSON: To understand what happened in the light of these two very different reports let's go back to the journey.

The night before the ditching the Pel-Air jet flew from Sydney to Samoa, stopping on the way at Norfolk Island to refuel.

Bad weather was forecast at Norfolk.

But the reality on the ground was different.

(Reconstruction of time in Samoa)

DOMINIC JAMES: When we arrived we could quite easily see all the stars, and obviously the forecast conditions hadn't eventuated. And the guy said 'oh that's a known issue with the automatic weather station at Norfolk, it overstates how bad the weather is.'

GEOFF THOMSON: With that belief lodged in his mind, Dominic James continued on to Samoa and arrived early in the morning.

It was hours before the flight crew got access to hotel rooms to get some - interrupted - sleep.

By now they'd been awake for more than 24 hours.

GEOFF THOMPSON: And how much sleep did you get?

DOMINIC JAMES: Not much. Couple of hours.

GEOFF THOMPSON: Were you tired?

DOMINIC JAMES: I didn't feel tired, no.

BRYAN AHERNE: It sounded like to me that he was fatigued. When you do the timelines, it's, it would be impossible for anyone to suggest otherwise.

HOUSEMAID (Reconstruction): (Knocking on door) House-keeping.

MICK QUINN: He misses two nights' sleep, basically. The accident happened on the second night of him missing sleep.

GEOFF THOMSON: CASA's special audit found that Pel-Air failed to comply with approved fatigue management systems. It concludes that:

(Reads audit report): "Pel-Air have not managed fatigue risk to a standard considered appropriate, particularly for an operator conducting ad hoc 24 hour medivac operations"

MARTIN DOLAN: There was an indication there fatigue may have had a role to play. But the evidence available to us wasn't such that we'd come to the definitive view that there was a major fatigue related element.

JOHN MCCORMICK: In the end it's only the pilot who can decide whether he is fatigued or he or she is fatigued and unable to conduct a flight.

GEOFF THOMSON: Before leaving Samoa, Dominic James tried to submit a flight plan for the return journey.

But he couldn't get an internet connection.

DOMINIC JAMES: The internet on the whole island was down,I wasn't going to be able to get online.

(Reconstruction): Yeah, good afternoon it's Dom James ...

GEOFF THOMSON: He rang Pel-Air, but the operations manager was unavailable.

DOMINIC JAMES (Reconstruction): ... to Norfolk Island ..

(On Four Corners): I then had to make a phone call to Air Services Australia and try and manage a phone briefing, which considering the normal briefings are fairly lengthy was a difficult procedure.

JOHN MCCORMICK: The pilot shows an appalling lack of knowledge of what he thinks that flight plan is going to do. He did not know the route on which he was going to fly, he did not know what times he was going to leave one, what's called flight information region, and enter another. He was unsure of the flight times, he guessed three-and-a-half hours, and that's actually on the transcript. Well you can't guess these things.

BRYAN AHERNE: His flight planning was basically on the run. There was no support structure. There was no software to assist him.

GEOFF THOMSON: CASA's audit also found that Pel-Air failed to support Westwind pilots making complicated fuel and flight planning calculations.

It said:

(Reads audit report): "There is no standardised method of flight planning. Many crew purchased their own software for planning and loaded their own fuel figures."

JOHN MCCORMICK: Software is only a thing of today. You know, you can do this manually. When I started flying 40 years ago of course software didn't exist. Examinations tested theoretical knowledge of how you conduct those calculations or you make those calculations. And they can be done by longhand as well as by computerised software.

GEOFF THOMSON: Flight planning over the phone, Dominic James was given a weather forecast for Norfolk Island.

It said there was unlimited visibility with scattered cloud at 2,000 feet.

This meant conditions were good for landing a plane.

What the pilot didn't know was that this weather report was atypical for that day.

MIKE QUINN: From a timing point of view, he just happened to be in the wrong place at the wrong time to get this forecast that was radically out of kilter with everything that had been issued prior and after this forecast that he got.

GEOFF THOMSON: Crucially, the good forecast meant he was not legally required to carry fuel to reach an alternate destination.

DOMINIC JAMES: The type of category that we were in, which is air work, which all aero-medical aircraft operate under, did not require us to carry an alternate for Norfolk Island.

GEOFF THOMSON: With no alternate destinations required Dominic James simply reversed his flight plan from the night before.

This would take him from Samoa to Melbourne via another fuel stop at Norfolk Island.

He chose not to island hop between closer refuelling stops in places like Fiji or Noumea.

DOMINIC JAMES: As a general rule the more remote the location the more expensive the fuel was. So being mindful of that you tried to get the fuel as close to Australia as you possibly could.

BRYAN AHERNE: The operators had always done direct from Samoa to Norfolk Island. So the pilot was just doing what he was told to do.

GEOFF THOMSON: CASA's Special Audit concluded that Pel-Air had breached the Civil Aviation Act.

It says:

(Reads audit report): "The significant deficiencies identified during the audit indicate that there exists an imbalance between commercial objectives and safety outcomes. This was most prevalent in the Westwind Aeromedical Operations."

GEOFF THOMPSON: Why are Pel-Air's breaches missing from the ATSB's report?

MARTIN DOLAN: Our report isn't about compliance with regulatory systems and so on. That is the role of CASA. That's why they undertook their investigation. Our role is to try and find out the overall system within which they're applying their rules and their oversight.

GEOFF THOMSON: With good weather forecast, Dominic James headed to Norfolk Island with his fuel tanks 83 per cent full.

The first weather update for Norfolk comes from Air Traffic Control in Fiji.

It says there's some cloud over Norfolk island at 6,000 feet.

This is wrong.

MICK QUINN: In review when you look at the actual weather report that was issued, the actual cloud base was not at 6,000 feet. It was at 600 feet.

That indicates to Dominic, it reinforces his mental picture, that the forecast still is as it was, it's even better than what it was when he got the original forecast when he departed.

MARTIN DOLAN: That's not one that I am familiar with at the level of detail in the report so ...

GEOFF THOMPSON: So it might be a mistake.

MARTIN DOLAN: It, it may well be a mistake. I'll have to take a look at that.

GEOFF THOMSON: And he did.

Last Friday the ATSB acknowledged Dominic James received incorrect weather report from Fiji and changed its report.

DOMINIC JAMES: If I'd been told that there was cloud at 600 feet, even given the fact that I suspected the automatic system was overstating the weather at Norfolk, I would've gone to Fiji.

GEOFF THOMSON: But moments later another weather report comes from Fiji which is acknowledged by the flight crew as the latest weather available.

It contradicts what they've just heard and says weather conditions on Norfolk Island are in fact deteriorating.

DOMINIC JAMES: I maintain that that weather report, exactly as it appears in that transcript, is not what we had on the flight deck. That's not what I copied down, it's not what I comprehended.

GEOFF THOMPSON: And how do you explain that?

DOMINIC JAMES: To be honest with you, I can't.

MICK QUINN: It's possible that there was an over-transmission and that maybe the flight crew only got part of that weather information. It's possible that they didn't assimilate that because the flight crew were fatigued.

GEOFF THOMPSON: The flight crew was criticised by the ATSB for not asking for the latest Norfolk Island forecast.

On this issue the ATSB report found that pilots needed more guidance from regulators, and identified as a minor safety issue.

But a 2010 letter from the ATSB to CASA about the ditching shows that the organisations had earlier agreed that it was an issue of critical safety importance.

This means it presented a level of intolerable risk.

MARTIN DOLAN: We were, if you like, being cautious and prudent. We were saying at that time, on what was available to us, a partial picture, it looked to be that sort of issue.

GEOFF THOMPSON: So it's gone all the way from being a critical safety issue, it skipped significant safety issue and went all the way down to minor safety issue. That's a pretty big jump.

MARTIN DOLAN: That's ... I wouldn't have said it was a jump, it was something that hanged over time

GEOFF THOMSON: On the ground at Norfolk, Unicom operator Larry Quintal had certainly noticed that the weather was getting worse.

And he was technically capable of telling Dominic James this himself via HF radio.

LARRY QUINTAL: We weren't being given permission to do that, use that HF frequency. We did enquire over a period of times whether you know whether there's a possibility that we can use it and it was refused, They say 'no we will stick to our VHF system and that would be used for Auckland'.

GEOFF THOMPSON: Do you wish you were allowed to use it on that night?

LARRY QUINTAL: Absolutely, absolutely.

GEOFF THOMSON: Larry Quintal did report bad weather to air traffic control in New Zealand.

MICK QUINN: He's sitting there looking out the window. He knows what it's like.

(Sound of radio communication with Auckland)

GEOFF THOMSON: He told Auckland there was cloud just 300 feet above the runway.

(To Larry Quintal): Were you under the impression, and have you believed until now, that that would have been passed on to Dominic James?

LARRY QUINTAL: Absolutely, yep. After all that sort of information's very important and it would have helped Dominic make a better decision.

MICK QUINN: The information is out there, several people know about it, but for some reason, it doesn't get back to the flight crew. And this is very critical information that, had that happened, possibly would have been the trigger to stop the accident sequence.

DOMINIC JAMES: When those weather reports came through, I had the fuel to make Fiji without difficulty. By the time nine o'clock rolled round, I was compelled to go to Norfolk and I had no other options.

GEOFF THOMSON: This is disputed by CASA and the ATSB.

They argue that at this point the jet still had enough fuel to divert to Noumea.

Such calculations are complex and time-consuming.

JOHN MCCORMICK: We calculate he would've landed with 400 pounds or 20 minutes of fuel remaining in the aeroplane. So even as late as the point of top of descent where he's about to commence his descent into Norfolk Island, or shortly before that, he still could've gone to Noumea.

DOMINIC JAMES: The calculations that were run by the specialists that were assisting me found that the amount of fuel I would've arrived at Noumea with was about eight minutes, which is way short of what was required to do it safely.

GEOFF THOMSON: Dominic James approached Norfolk Island still convinced it was his safest bet.

DOMINIC JAMES: It was only once I'd commenced my descent to Norfolk and had spoken to Larry on the short-range, better quality VHF radio, that I became concerned that the conditions were actually a lot different to what I'd expected.

GEOFF THOMSON: The ATSB report does acknowledge that Pel-Air could have done more to minimise the risks associated with aeromedical flights to remote islands.

But inexplicably the report concludes that Pel-Air did operate within the regulations.

MARTIN DOLAN: One of the fundamental assumptions of the role of the independent no blame investigator is that we're not in the business of saying this is who is to blame and a range of other things. It's what is the system that's in place and what needs to be done to improve it.

GEOFF THOMSON: Tellingly, after its audit of Pel-Air, CASA demanded a root and branch overhaul of its operations.

JOHN MCCORMICK: Pel-Air have addressed every one of the issues that we found in that special audit report. As I said, we put them as conditions on their air operators certificate, their licence to operate, until they cleared each and every one of those issues.

DOMINIC JAMES: One of the major things that's changed is all the remote islands that surround Australia are now no longer able to be used as refuelling stops. And the aircraft are now required to go the long way around and use air-airports that are surrounded by alternates nearby.

GEOFF THOMSON: The company's leaders have declined to be interviewed by Four Corners.

Pel-Air has moved on.

(Footage of Bernie and Gary Currell at home)

BERNIE CURRALL: (Packing) You'd think I was going for two years wouldn't you?

GEOFF THOMSON: The same can't be said of those who survived the ditching of Pel-Air flight VH-NGA.

BERNIE CURRALL (To her dog): Trixie I'm going to miss you, yes I am.

(On Four Corners): My kids find it really hard because this is just not who I was.

GEOFF THOMSON: Bernie Currall is packing.

She's booked into a mental health clinic for the ninth time since she crashed into the ocean strapped to a stretcher.

BERNIE CURRALL: Just one day it all just came crashing down. Everything just hit me. I was just this crying wreck in the car who had lost complete control of her bowels and my urine. I was just this mess.

(Footage of Bernie and Gary Currall in the car on the way to the clinic plays)

GARY CURRALL (to Bernie): Are you nervous?

BERNIE CURRALL: Yep. They're very nice I just don't want to go.

GEOFF THOMSON: Bernie's been diagnosed with chronic Post Traumatic Stress Disorder.

GARY CURRALL (to Bernie): It'll do you good in the long run.

GEOFF THOMSON: She can't work. She can't even read a book.

GARY CURRALL (to Bernie): It'll get you well

BERNIE CURRALL: Yeah, hopefully

(On Four Corners): All the medication that I have to take to get me to get through the day every day is just, it's enormous amounts.

(Footage of Bernie arriving at the mental health clinic plays)

(At clinic): OK so this is my room for the next couple of weeks.

GEOFF THOMSON: Bernie's treatments are expensive.

Gary teaches during the day and washes dishes at a hospital at night, just to keep up.

BERNIE CURRALL (to Gary Currall): Love you and I'm going to miss you.

GEOFF THOMSON: Like all those in the jet's cabin that night, Bernie and Gary are pursuing Pel-Air for compensation.

GARY CURRALL: There's been no contact whatsoever with Pel-Air in the two-and-a-half years since the accident. No contact whatsoever.

GEOFF THOMPSON: Is that shocking for you?

GARY CURRALL: It's just appalling. It's yeah, it's beyond words.

(Footage of Karen Casey being treated)

DR SUNDARAJ (to Karen Casey): What happens there? That's tender?

(Karen Casey cries)'

What about here?

(Karen Casey, crying, shakes her head)

Squeeze my fingers both hands. That's so much stronger, this is really weak'.

GEOFF THOMSON: Neither can words describe the pain Karen Casey now endures.

DR SUNDARAJ (to Karen Casey): I can see you've wasted. These muscles here are so much smaller compared to this side. This is due to the nerve injury.

GEOFF THOMSON: The impact of the ditch effectively wrenched the roots of Karen's nerves away from her spine.

DR SUNDARAJ: Is that hurting you a lot?

GEOFF THOMSON: Her right arm is practically useless.

DR SUNDARAJ: That's hurting you?

KAREN CASEY (to Dr Sundaraj): It's the loss (sobs) I've reached a limit.

DR SUNDARAJ: I'm afraid it's going to be with you for a long time.

(Footage of Karen Casey working plays)

GEOFF THOMSON: Karen grieves for the busy life she's lost as working mum caring for her three children.

Like Bernie, she hasn't worked since the ditch.

KAREN CASEY: That's what really gets me down. I do OK, I do OK with everything else that's happened, with loss, I don't know where my future is going to take me. I don't know whether to study, but the pain is the one that drives me insane.

GEOFF THOMSON: Dominic James now flies charters and trains other pilots on the outskirts of Sydney.

CASA has reinstated most of his licences.

He still keeps a tiny torch within easy reach.

DOMINIC JAMES: I didn't operate in a vacuum. I operated as a pilot that belonged to a company that was overseen by a regulator. You can't isolate one thing from all the others and say that's a fair appreciation of what took place.

GEOFF THOMSON: Almost three years on, perhaps the only certainty is that six people miraculously survived thanks to the vigilance of Norfolk Islanders and a whole lot of luck.

KERRY O'BRIEN: You might say the lessons of that near tragedy are now clear. But have they really been learned?

All the documents referred to in the story, including CASA's special audit are on our website if you're looking for more detail.

Next week on Four Corners, the shocking impact of youth suicide. Is it time to be more open about its prevalence and its consequences?

Until then, good night.

END

Background Information

PROGRAM UPDATES

Pel-Air and CASA damned by safety audit documents | Crikey.com | 4 Sep 2012 - The only tenable conclusion that can be made from the Pel-Air disclosures on 4 Corners last night is that the performances of CASA and the ATSB are so bad that they constitute a threat to public safety in Australia. By Ben Sandilands.

CASA caught playing the man not the company in ABC TV exposon Pel-Air ditching | Crikey.com | 3 Sep 2012 - The ABC TV 4 Corners report into the Norfolk Island Pel-Air ditching has this evening shown CASA's director of safety, John McCormick, making an attack on the flight's captain, Dominic James and excusing every single deficiency the regulator uncovered in the company during a safety audit as not being a cause of the accident.

Pel-Air Media Release | 3 Sep 2012 - The Australian Transport Safety Bureau (ATSB) has released its Final Report on the investigation of the ditching of the Westwind aircraft off Norfolk Island in November 2009 and Pel-Air accepts all the findings of the report. Read more... [PDF 67Kb]

RESPONSE FROM PEL-AIR TO FOUR CORNERS' QUESTIONS

Response from Pel-Air to 4 Corners - Read the response from Pel-Air to questions sent by Four Corners in relation to the findings of the investigation into the ditching of a Pel-Air jet in the sea off Norfolk Island, in 2009. [PDF 405Kb]

KEY REPORTS AND DOCUMENTATION

CASA Special Audit | 2009 - The CASA Special Audit into Pel-Air after the ditching off Norfolk Island in 2009. [PDF 3.35Mb]

ATSB Letter to CASA | 2010 - The letter between ATSB and CASA agreeing that lack of regulatory guidance for pilots re weather reports is a 'critical safety issue'. [PDF 432Kb]

Ditching - Israel Aircraft Industries Westwind 1124A , Norfolk Island | Australian Transport Safety Bureau (ATSB) | 18 Nov 2009 - On 18 November 2009, an Israel Aircraft Industries Westwind 1124A aircraft, registered VH-NGA, ditched in the ocean 3 NM (6 km) to the west of Norfolk Island. The six occupants evacuated the sinking aircraft and were later recovered by a rescue vessel from Norfolk Island... Following the event, the aircraft operator initiated a program of checking and revalidation for the company's commercial Westwind pilots. The investigation has now concluded. Visit the investigation page.

ATSB Final Report | Aug 2012 - Download the final report. [PDF 2.28Mb]

ATSB Preliminary Report | Jan 2010 - Download the preliminary report. [PDF 1Mb]

Download the video showing footage of the ditched Pel-Air Westwind jet on the sea bed, off the coast of Norfolk Island. [MP4]

NEWS AND COMMENTARY

Hard lessons learnt from Pel-Air ditching | The Australian | 31 Aug 2012 - A seres of mistakes by the crew operating a Pel-Air medical evacuation flight, which led to the plane ditching off Norfolk Island almost three years ago, has prompted the development of new regulations on fuel planning, inflight management and alternate airports.

Pel-Air ditching report hurts more as it sinks in | Crikey.com | 30 Aug 2012 - The most damning thing about the ATSB final report into the ditching and sinking of a Pel-Air operated air ambulance flight near Norfolk Island in November 2009 is that CASA, the air safety regulator, almost three years later, hasn't enforced the same flight safety standards on such operations as it requires from normal passenger jet services. By Ben Sandilands.

Pel-Air slammed in Norfolk Island ditching report | Crikey.com | 30 Aug 2012 - The ATSB's report into the 2009 ditching of an air ambulance flight by Pel-Air in the sea in the middle of the night just before its tanks were going to run empty on a flight where it was inadequately fueled for its mission has been released. The PR summary for media below is, as usual, comparatively restrained considering the enormity of the situation.

Pel-Air air ambulance ditching report due Thursday | Crikey.com | 27 Aug 2012 - The long awaited final report into the 18 November 2009 ditching of a Pel-Air air ambulance flight into the sea at night near Norfolk Island will be released this Thursday.

The crash that goes on forever | SMH | 31 Mar 2012 - There is still no resolution for those aboard the Pel-Air jet ditched at sea, writes Damien Murphy.

Air ambulance crash pilot suspended despite heroic landing | The Australian | 24 Feb 2010 - The air safety watchdog has suspended the licence of the pilot hailed as a hero after last year's ditching of an air ambulance off Norfolk Island.

ATSB report makes Pel-Air, its pilot and CASA look like fools | Crikey.com | 13 Jan 2010 - It is made graphically clear by the ATSB interim report into the November 18 ditching of a Pel-Air Westwind jet off Norfolk Island that the six people on board variously rushed or struggled for their lives.

CASA changes fuel rules as Pel-Air crash report draws nearer | Crikey.com | 15 Jul 2010 - The air safety regulator, CASA, has proposed fuel rule changes which would have outlawed the conduct of the Pel-Air aerial ambulance flight that ditched into the sea near Norfolk Island last November 18.

Norfolk pilot 'flew without enough fuel' | ninemsn | 21 Nov 2009 - The pilot hailed a hero for ditching his plane safely off Norfolk Island this week may have been dangerously negligent after reportedly making the journey without enough fuel.

Miracle landing on Norfolk Island | Radio National | 20 Nov 2009 - On Wednesday night, a heavy cloud stopped Captain Dominic James from landing his Air Ambulance on Norfolk Island, en route from Samoa to Melbourne. Not only did Captain James manage to land his plane in the rough seas in darkness, but he also got all five passengers, including a seriously ill Australian woman, out of the aircraft moments before it sank. They then waited in shark-infested waters for a fishing boat to rescue them.

LINKS

Australian Transport Safety Bureau - www.atsb.gov.au/

Aviation Safety Network (ASN) - An online resource for aircraft accidents and civil aviation safety issues. aviation-safety.net/

Civil Aviation Safety Authority - www.casa.gov.au/

International Civil Aviation Organization (ICAO) - Promotes understanding and security through cooperative aviation regulation. www.icao.int/

Pel-Air Aviation - www.pelair.com.au/

Blog: PlaneTalking - Ben Sandilands provides the latest aviation and travel news on Crikey.com. blogs.crikey.com.au/planetalking/

The PPRuNe Forums (The Professional Pilots Rumour Network) - Discussion board for pilots. www.pprune.org/

WATCH RELATED FOUR CORNERS PROGRAMS

QF32 | 28 Mar 2011 - Sarah Ferguson's gripping account of how a single engine part almost brought down the pride of the Qantas fleet. Flash Video Presentation