Date & Time: Apr 9, 2008 at 2327 LT
Operator:
Registration:
VH-OZA
Flight Phase:
Takeoff (climb)
Flight Type:
Cargo
Survivors:
No
Schedule:
Sydney-Brisbane
MSN:
AC-600
YOM:
1984
Country:
Australia
Region:
Oceania
Crew on board:
1
Crew fatalities:
0
Pax fatalities:
0
Other fatalities:
0
Total fatalities:
1
Captain / Total flying hours:
4873
Captain / Total hours on type:
175
Aircraft flight hours:
32339
Aircraft flight cycles:
46710
Circumstances:
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.
Probable cause:
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.