09APR2008 at 2327LT

Swearingen SA227AC Metro III

Avtex Air Services

VH-OZA

Off Bundeena

Sydney - Brisbane

Construction number

AC-600

Year of manufacture

1984

Crew on board

1

Pax on board

0

Crew fatalities

1

Pax fatalities

0

Other fatalities

0

1

Shortly after takeoff at night, the pilot followed a wrong track outbound for Brisbane. ATC requested the reasons of that route change and the pilot reported minor technical problem. The twin engine aircraft eventually crashed in sea 8 km off Bundeena. The pilot was killed in the accident.

Contributing safety factors
• It was very likely that the aircraft’s alternating current electrical power system was not energised at any time during the flight.
• It was very likely that the aircraft became airborne without a functioning primary attitude reference or autopilot that, combined with the added workload of managing the "slight technical fault", led to pilot spatial disorientation and subsequent loss of control.
Other safety factors
• The pilot’s Metro III endorsement training was not conducted in accordance with the operator’s approved training and checking manual , with the result that the pilot’s competence and ultimately, safety of the operation could not be assured. [Significant safety issue]
• The chief pilot was performing the duties and responsibilities of several key positions in the operator’s organisational structure, increasing the risk of omissions in the operator’s training and checking requirements.
• The conduct of the flight single-pilot increased the risk of errors of omission, such as not turning on or noticing the failure of aircraft items and systems, or complying with directions.