What happened
On October 22, 2009, a Britten-Norman Islander operated by Divi Divi Air performed an emergency landing at sea near Bonaire. The incident involved a single-pilot operation and resulted in a ditching in the ocean.
The investigation
The Dutch Safety Board investigated the circumstances leading to the ditching. The inquiry examined the operator's loading procedures, pilot training protocols, and the accuracy of onboard safety instructions. The investigation looked into how weight and balance information was communicated to the pilot and whether the safety equipment, such as life vests, was properly documented in the aircraft's safety cards.
Findings
At the time of the accident, there were discrepancies in the safety instructions provided to passengers, as the onboard safety cards did not accurately reflect the specific safety vests being used in the aircraft. Furthermore, the investigation highlighted the critical importance of pilot responsibility in single-pilot operations, noting that the decision to continue the flight despite existing conditions was a key factor in the event.
Safety action
In response to the findings, Divi Divi Air has implemented several structural changes to its safety management system:
- The passenger and cargo loading program was upgraded to include written documentation. Pilots must now sign for acknowledgment of the load weight and passenger count, and are required to cross-reference these figures against the general declaration and weight and balance sheets.
- The pilot training program was developed to align with the Britten-Norman Islander Pilot Handbook, including specific new briefings regarding the use of flaps during ditching procedures.
- The onboard safety cards were reprinted to accurately reflect the use of available safety vests and submitted to the CCAA for approval.
- Enhanced monitoring is now in place, with office records of fuel slips, payload information, and weight and balance sheets being reviewed to ensure compliance with safety standards.