There is still no resolution for those aboard the Pel-Air jet ditched at sea, writes Damien Murphy.
The plane ran out of fuel. Six words unspoken by most everyone who flies but a terrifying reality for nurse Karen Casey sitting in the cabin of a yawing Pel-Air Westwind jet after an aborted third landing on Norfolk Island one stormy November night 28 months ago.
The island was buried in the universal darkness and for 45 minutes the pilot had been unable to see airport landing lights, so he banked the twin-engine jet once more.
''I looked out the window and could not see anything; the cloud was dark grey and thick, there was no visual,'' Casey recalls. ''The co-pilot turned her head and said hurriedly, 'We are going to try a fourth approach, if we can't do it, we will have to ditch in the ocean. Get your life vests ready.'''
Nearly 2½ years later, the Norfolk Island ditching remains a behind-closed-doors affair, as bureaucracies dither or pass the buck.
Incredibly, the Australian Transport Safety Bureau's final report is still two months off.
A 60-page draft of that report has been circulated for discussion but sources say it has been so ''dumbed down'' the recommendations do not address regulatory problems highlighted by the ditching.
''Word in the industry is that a political fix is in so nobody would be offended,'' one aviation figure said.
''There is nothing in the report that suggests the Reason model of accident causation was even remotely considered. That model should develop a schematic interaction between individual error and factors such as faulty top level management decisions. Instead, there's nothing of the sort.''
The bureau is staying mum until the final report is published.
Australian registered aircraft can still fly the Pacific under regulations that have clearly failed, yet the Civil Aviation Safety Authority has done little but suspend the pilot, only to reinstate him after he hired a lawyer.
Pel-Air will not discuss the ditching. A wholly owned subsidiary of the regional carrier Rex, Pel-Air continues to win multimillion-dollar government contracts but refuses to say if it has changed any practices that may have led to the crash.
Mick Quinn, an aviation safety expert with years of crash investigations behind him, hopes the findings won't scapegoat the pilot because the ditching raised questions about route qualifications, fuel policy and crew resource management.
''People make decisions based on context and circumstances dictate them, so it's important that contextual and organisational issues are at the forefront of recommendations,'' Quinn said.
''[Chesley] 'Sully' Sullenberger put the Airbus down on the Hudson River a few months before and he is a national hero in the US. He did it in daylight with ferries all around to pick up people. The Norfolk ditching was a world first, a jet, at night and with no fatalities. An astounding achievement. We should be learning from this rather than just looking for someone to blame. But I'm unsure if any of the authorities have even seized on the idea that this could be a valuable learning experience.''
Some of the survivors have got on with their lives. Others lost jobs or suffer painful and continuing injuries as government and big business remain silent and insurance companies play compensation poker.
Karen Casey, a nurse educator with CareFlight, suffered spinal and neck injuries, smashed teeth and post-traumatic stress. She has not worked since the crash and doubts she will ever nurse again. She's on workers' compensation but with no penalties and the end of exciting work that offered travel and jobs on the motor car racing circuit. The life she knew is a foreign place now.
''Some days are so bad I can't get out of bed. I know I shouldn't think it, but maybe it would have been better if I'd not survived,'' Casey said. ''One of my kids, Jemma, puts it best: 'We've lost our mum. She's just a ghost now.'''
On November 17, 2009, Pel-Air jet November Golf Alpha was sent from Sydney to Samoa to pick up a Scottish woman suffering septicaemia, the result of a hysterectomy gone wrong. An emergency flight, the aircraft left Apia the following evening bound for specialist care at the Royal Women's Hospital in Melbourne with six on board - Casey; an English doctor, David Helm; patient Bernie Currall; her husband, Gary Currall; co-pilot Zoe Cupit; and pilot Dominic James.
Flying at more than 10,000 metres altitude to reduce fuel consumption, and opting not to fill wing fuel tanks to reduce weight, all sanctioned by the rules, James planned to refuel on Norfolk Island. Tontouta Airport on Noumea was closer but the French fuel was much more expensive. By the time the Norfolk weather deteriorated, James had flown past the point of no return. The Australian coast was too far and the Noumea option had faded out of reach. Norfolk was clagged in when the jet arrived soon after 10pm and James tried four passes.
The aircraft had about 15 minutes' worth of fuel in the tank when James decided to ditch.
When the order to assume the brace position went out, Casey, a divorced single mother of three, felt the tears start.
''I felt sadness because of my children, leaving them behind so soon. They are not yet old enough to take care of themselves,'' she said. ''My daughters and I have a beautiful mother-daughter bond and I worried how they would cope without me.
''My son, the thought of never giving him a hug again, or saying goodnight. Thoughts raced through my mind about not being there for Amy's TAFE, Jemma's schooling and my son, Jesse, watching movies with him and laughing.
''How could it happen like this, to die at my age, 39, with three kids who depend on me?
''I hoped that I would die instantly and not be trapped, catapult, drown slowly or be eaten by sharks.
''We did not know when the impact would happen as it was so dark we could not see the ocean and there was a storm. The only sound I heard was the aircraft siren 'terrain terrain, pull up pull up'. All of a sudden I felt and heard the loudest bang of my life. I thought we hit concrete. Instantly water splashed onto my face and around my feet.''
James put the plane into the drink six kilometres west of Norfolk Island. It broke in two and sank within three minutes.
Somehow in the pitch black the six evacuated but only had three lifejackets between them. Some could not swim and needed to be kept afloat.
All were cut and bleeding. Freezing, no one mentioned sharks, but every time they kicked each others' legs fear surged into their chests.
''Bernie was fabulous to have by my side,'' Casey said. ''She fuelled my determination and we would often repeat, 'I'm not f---ing dying tonight, no f---ing way.'''
They thought they saw five rescue boats but none came and then the pilot remembered an LED torch, and an airport fireman who had a hunch the plane could have gone down west of the island saw the faint glow.
They were picked up after 90 minutes in the water. The sea was so rough the rescue boat was winched onto the jetty at Norfolk Island's main settlement of Kingston. The ditching and the media coverage it attracted swerved haphazardly between Boy's Own heroics and condemnation.
The pilot was lionised initially for the first ditching of a passenger jet in Australian waters with no loss of life. James was almost a gift from central casting for Pel-Air. The company was chasing multimillion-dollar aeromedical contracts. Their pilot was not only a dashing hero but a hunk, a former Cleo Bachelor of the Year contestant.
Amid the welter of publicity, the Civil Aviation Safety Authority suspended him on Christmas Eve 2009 and media coverage turned against him. Three months later the Nine Network's 60 Minutes program hung him out to dry. Gary Currall and his wife, Bernie, were particularly critical of James but Casey remembers him as cool under pressure and a tower of strength in the water.
CASA made James resit examinations and he worked as a barista for almost two years while challenging his suspension through the Administrative Appeals Tribunal. Late last month James put a lawyer on his case and CASA folded, returning his licence about three weeks ago and he is now back in the cockpit.
In January 2010 the Australian Transport Safety Bureau published an interim report into the ditching: ''It … highlights the risks in operating long distance flights to remote island locations which are subject to rapidly changing weather conditions.''
The ditching came at a delicate time for Pel-Air and the bureaucracy.
Pel-Air had just been audited by authorities and only months earlier the company had beaten the Royal Flying Doctor Service to a $70 million Victorian medical aviation contract and was attempting to wrest a 10-year multimillion-dollar NSW aeromedical contract from the RFDS. More than 10,000 people around NSW signed a petition calling for the RFDS to retain the contract and, just days after the ditching, the then Labor government, under then premier Nathan Rees, opted against Pel-Air.
Carmel Tebbutt, the deputy premier, said the RFDS offered the best value for money.