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Norfolk Island ditching pilot returns fire on investigators 'without a backbone'

To some he remains Australia's equivalent of Chesley "Sully" Sullenberger, the captain who landed a passenger plane on New York's Hudson River.

While Dominic James was initially hailed a hero for successfully ditching a Pel-Air jet in rough seas and pitch darkness off Norfolk Island without the loss of life, he quickly came under fire for his role in the incident.

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What cost surviving a plane crash?

In 2015, Four Corners investigated the shocking tale of nurse Karen Casey, who was on an air ambulance flight when the plane crash-landed into the ocean. She saved the life of her patient but sustained crippling injuries. Vision courtesy ABC.

Almost eight years to the day after the accident, the Australian Transport Safety Bureau has released a 531-page final report, the second it has issued on the crash that left two people badly injured.

In it, the bureau's investigators are again critical of Mr James but also raise concerns about inadequacies with the country's aviation regulations and the risk-control measures of Pel-Air, a subsidiary of NSW airline Regional Express which was operating the air-ambulance flight on November 18, 2009.

The ATSB reopened the investigation several years ago into what has been one of the most miraculous – yet equally controversial – incidents in modern Australian aviation history, following a senate inquiry that castigated both the bureau and the Civil Aviation Safety Authority for their handling of the matter.

And Nick Xenophon, who instigated that senate inquiry, said on Thursday that it remained a "deeply flawed and conflicted process".

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"Dominic James is a scapegoat for the regulatory failures and nothing short of a fully independent inquiry will bring the truth out," he said.

Remarkably, air ambulance flights remain classified as "aerial work" rather than charter, which means they are not subject to the same rigors as other passenger planes. This is despite CASA looking to change their classification five years ago.

The Westwind jet he was piloting was carrying a seriously ill patient, Bernie Currall, husband Gary, doctor David Helm and nurse Karen Casey from Samoa to Melbourne, when bad weather disrupted a planned fuel stop at Norfolk Island.

After four aborted attempts to land at Norfolk Island due to low cloud, Mr James and co-pilot Zoe Culpit ditched the plane into the ocean, where it broke into pieces and rapidly sank to the sea floor 48 metres below.

Mr James, who is still an air-ambulance pilot and has had the backing of a senior aviation safety expert, told Fairfax Media that the latest report "doesn't solve anything" in making the skies safer.

"I flew to Norfolk Island four months ago for the first time and several people that were there at the time [of the accident in 2009] greeted me," he said.

"I asked them what has changed, and they said nothing. There is not a single regulation that has changed that would stop this – that is a gigantic failure."

The report found Mr James's pre-flight planning lacked many elements needed to lower the risk of a long-distance flight to a remote island, including miscalculating the total amount of fuel required.

But Mr James, who lives on Sydney's north shore, said the ATSB had slammed his conduct but did not "want to rock the boat" when it came to criticising the system and parts of the aviation bureaucracy.

"They have lost their nerve – they are not courageous," he said.

"They are scathing when they criticise me. Everyone [else] has a let-off and an excuse. It is a failure in process and a failure in result.

"If the ATSB and CASA were doing their job and everything was done appropriately and transparently, you don't have a senate inquiry, you don't have Canadian investigators roped in and you don't have a safety review."

The report explains at length failures in the pre-flight planning needed to ensure the plane had adequate amounts of fuel in its tanks.

But Mr James said a larger tank of fuel would not have changed the outcome that day – he would still have had to ditch the plane in the ocean.

Instead, he said a lack of information about the rapidly deteriorating weather that day was a major factor glossed over.

"For two-and-a-half hours of that flight, there were about four significant opportunities for air traffic control to look at the information in front of them and pass it onto me. All of these opportunities were missed," he said.

The report does note that air traffic controllers in Fiji and New Zealand "did not provide the flight crew with all the information that should have been provided".

Asked if he deserved criticism, Mr James said: "There are things that I would have done differently but they don't radically change the outcome of the accident.

"If you put anyone else in the pilot's seat that night, it is more than likely that they would find themselves in the same situation. The thing that I want most is for the ATSB to grow a backbone but they haven't."

But the ATSB said the investigation found 36 safety factors, including 16 safety issues, which would provide lessons to the regulator, flight crews, operators, and other organisations to help prevent such an accident happening again.

"It is not unusual that some parties may not agree with the ATSB's findings. However, the ATSB is confident that the report's analysis and findings are well supported by the evidence gathered and have undergone appropriate peer and management review," a spokesman said.

For Karen Casey, the nurse aboard the flight, the captain has become a scapegoat for this country's aviation bureaucracy.

"I was there – he saved our lives. He is definitely a hero to me," she said. "There's no closure and there won't be until I can see safety enhanced within our organisations. It is a culture that needs to be shaken up."