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Crash of a Cessna 402C in Papa Lealea

Date & Time: Jul 26, 2020 at 1246 LT
Type of aircraft:
Operator:
Registration:
VH-TSI
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Papa Lealea - Mareeba
MSN:
402C-0492
YOM:
1981
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 26 July 2020, at 12:46 local time (02:46 UTC), a Cessna 402C aircraft, registered VH-TSI collided with trees during an aborted take-off at an uncommissioned field near Papa-Lealea, about 16 nm North-West of Port Moresby, Papua New Guinea. The pilot, during interview with the AIC, stated that he departed at 09:30 that day from Mareeba Airport, Queensland Australia and tracked towards the North North-East with a planned track set slightly left of Jacksons International Airport, Port Moresby, National Capital District, Papua New Guinea. As the aircraft neared the Southern shoreline (within the Caution Bay area), he diverted left and began tracking towards the North West along the coast in order to avoid flying over villages in the area. He subsequently crossed over land before turning back to approach the intended landing field. As the aircraft approached to land, the outboard section of the left wing was clipped by a tree and separated from the aircraft. According to the pilot, he continued on with the approach and landed on the field at about 12:20. The pilot reported that he had flown to and within Papua New Guinea in the past and was familiar with the area and airspace. He confirmed that after departing Mareeba, he switched off the transponder. After shutting down the aircraft, the aircraft was refuelled with jerrycans full of fuel (AvGas) and loaded with cargo by persons waiting on the ground. The pilot reported that he estimated that a distance of 800 m would be required for the take-off. According to the pilot, at about 12:40, he lined up and commenced his take-off roll from the Southern end of the field. As the aircraft lifted off, he noticed that the airspeed indicator (ASI) was not working. He also observed that the aircraft was not achieving a positive rate of climb. He subsequently pulled the throttles back and manoeuvred the aircraft back towards the ground. The aircraft touched down with a speed that the pilot described as higher than normal, with about 400 m of usable field remaining. The aircraft continued off the end of the field and into the bushes clipping trees along the way until it came to rest. The pilot informed the AIC that he was the sole occupant of the aircraft, and sustained minor injuries as a result of the occurrence. The aircraft was substantially damaged. The investigation confirmed that the fire to the left wing and engine was a post-accident event and was deliberate. The pilot was later arrested and a load of 500 kilos of cocaine distributed in 28 bales was found at the scene.
Probable cause:
The investigation determined that the separation of the outboard section of the left wing, clipped by a tree during the approach to land phase, affected the ability of the left wing to produce lift. The investigation could not conclusively determine the actual weight and balance of the aircraft as it was not possible to determine the quantity and quality of fuel on board, nor the weight and distribution of the cargo that was on board. The evidence gathered during the investigation did not allow the AIC to discard overweight, balance or centre of gravity issues due to improper loading or restrain of the cargo as factors contributing to the inability of the aircraft to obtain a positive rate of climb during take-off. The evidence of tire marks found by the investigators on the uncommissioned field indicated that the aircraft touched down about 400 m before the end of the field, distance that was not enough for the aircraft to come to a stop, continuing its landing roll into the bushes and impacting trees until it got to its final position. The investigation determined that the aircraft was not airworthy at the time of the accident and was unserviceable for the conduct of the flight. The investigation also determined that there was no proper document control to conduct timely scheduled maintenance and that there was no record of a certificate of airworthiness (CoA) at the time of the accident.
Final Report:

Crash of a Grumman G-73 Mallard in Perth: 2 killed

Date & Time: Jan 26, 2017 at 1708 LT
Type of aircraft:
Operator:
Registration:
VH-CQA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Serpentine - Serpentine
MSN:
J-35
YOM:
1948
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
625
Captain / Total hours on type:
180.00
Circumstances:
On 26 January 2017, the pilot of a Grumman American Aviation Corp G-73 amphibian aircraft, registered VH-CQA (CQA), was participating in an air display as part of the City of Perth Australia Day Skyworks event. On board were the pilot and a passenger. The pilot of CQA was flying ‘in company’ with a Cessna Caravan amphibian and was conducting operations over Perth Water on the Swan River, that included low-level passes of the Langley Park foreshore. After conducting two passes in company, both aircraft departed the display area. The pilot of CQA subsequently requested and received approval to conduct a third pass, and returned to the display area without the Cessna Caravan. During positioning for the third pass, the aircraft departed controlled flight and collided with the water. The pilot and passenger were fatally injured.
Probable cause:
From the evidence available, the following findings are made regarding the loss of control and collision with water involving the G-73 Mallard aircraft, registered VH-CQA 10 km west-south-west of Perth Airport, Western Australia on 26 January 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual. Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.
Contributing factors:
- The pilot returned the aircraft to the display area for a third pass in a manner contrary to the approved inbound procedure and which required the use of increased manoeuvring within a confined area to establish the aircraft on the display path.
- During the final positioning turn for the third pass, the aircraft aerodynamically stalled at an unrecoverable height.
- The pilot's decision to carry a passenger on a flight during the air display was contrary to the Instrument of Approval issued by the Civil Aviation Safety Authority for this air display and increased the severity of the accident consequence.
Final Report:

Crash of a Piper PA-31-310 Navajo C in Aldinga

Date & Time: Jan 29, 2014 at 1132 LT
Type of aircraft:
Operator:
Registration:
VH-OFF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Aldinga - Kangaroo Island
MSN:
31-7812064
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 29 January 2014, at about 1100 Central Daylight-savings Time, the pilot prepared a Piper PA-31 aircraft, registered VHOFF, for a private flight from Aldinga aeroplane landing area (ALA) to Kangaroo Island, South Australia. To check fuel quantities, the pilot entered the cockpit, turned on the master switch and placed the left and right fuel selectors onto the main tank (inboard) position. The gauge for each tank showed just under half full. He then placed each fuel selector onto the auxiliary (outboard) tank position, where the gauge indicated the right and left auxiliary tanks were each about a quarter full. He did not return the selectors to the main tanks. He estimated that refuelling the main tanks would allow sufficient fuel for the flight with over an hour in reserve. He exited the aircraft while it was refuelled and continued preparing for the flight. Once refuelling was completed, the pilot conducted a pre-flight inspection, and finished loading the aircraft. The pilot and passenger then boarded. The pilot was familiar with Aldinga ALA, which is a non-controlled airport. At uncontrolled airports, unless a restriction or preference is listed for a certain runway in either the Airservices en route supplement Australia (ERSA), or other relevant publications, selection of the runway is the responsibility of the pilot. Operational considerations such as wind direction, other traffic, runway surface and length, performance requirements for the aircraft on that day, and suitable emergency landing areas in the event of an aircraft malfunction are all taken into consideration. On this day, the pilot assessed the wind to be favoring runway 14, which already had an aircraft in the circuit intending to land. However, he decided to use runway 03 due to the availability of a landing area in case of an emergency. He then completed a full run-up check of the engines, propellers and magnetos prior to lining up for departure. The pilot reported that all of the pre-take-off checks were normal. Once the aircraft landing on runway 14 was clear of the runway, the pilot went through his usual memory checklist prior to take-off. He scanned and crosschecked the flight and panel instruments, power quadrant settings and trims, but did not complete his usual final check, which was to reach down with his right hand and confirm that the fuel selector levers were on the main tanks. After broadcasting on the common traffic advisory frequency (CTAF) he commenced the take-off. At the appropriate speed, he rotated the aircraft as it passed the intersection of the 14 and 03 runways. Almost immediately both engines began surging, there was a loss of power, the power gauges fluctuated and the aircraft yawed from side to side. Due to the surging, fluctuating gauges and aircraft yaw, the pilot found it difficult to identify what he thought was a non-performing engine. He reported there were no warning lights so he retracted the landing gear, with the intent of getting the aircraft to attain a positive rate of climb, so he could trouble shoot further at a safe altitude. When a little over 50 ft above ground level (AGL), he realized the aircraft was not performing sufficiently, so he selected a suitable landing area. He focused on maintaining a safe airspeed and landed straight ahead. The aircraft touched down and slid about another 75-100 metres before coming to rest. The impact marks of the propellers suggest the aircraft touched the ground facing north-easterly and rotated to the north-west prior to stopping. The pilot turned off the master switch and both he and the passenger exited the aircraft. After a few minutes he re-entered the cockpit and completed the shutdown. Police and fire service attended shortly after the accident.
Probable cause:
Engine malfunction due to fuel starvation.
Final Report:

Crash of a De Havilland DH.84 Dragon near Borumba Dam: 6 killed

Date & Time: Oct 1, 2012 at 1413 LT
Type of aircraft:
Operator:
Registration:
VH-UXG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Monto - Caboolture
MSN:
6077
YOM:
1934
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
1134
Captain / Total hours on type:
662.00
Circumstances:
At about 1107 Eastern Standard Time on 01OCT2012, a de Havilland Aircraft Pty Ltd DH-84 Dragon, registered VH-UXG (UXG), took off from Monto on a private flight to Caboolture, Queensland under the visual flight rules (VFR). On board the aircraft were the pilot/owner and five passengers. The weather conditions on departure were reported to include a light south-easterly wind with a high overcast and good visibility. Sometime after about 1230, the aircraft was seen near Tansey, about 150 km north-west of Caboolture on the direct track from Monto to Caboolture. The aircraft was reported flying in a south-easterly direction at the time, at an estimated height of 3,000 ft and in fine but overcast conditions. At 1315, the pilot contacted Brisbane Radar air traffic control (ATC) and advised that the aircraft’s position was about 37 NM (69 km) north of Caboolture and requested navigation assistance. At 1318, the pilot advised ATC that the aircraft was in ‘full cloud’. For most of the remainder of the flight, the pilot and ATC exchanged communications, at times relayed through a commercial flight and a rescue flight in the area due to the limited ATC radio coverage in the area at low altitude. At about 1320, a friend of one of the aircraft’s passengers received a telephone call from the passenger to say that she was in an aircraft and that they were ‘lost in a cloud’ and kept losing altitude. Witnesses in the Borumba Dam, Imbil and Kandanga areas 70 to 80 km north-north-west of Caboolture later reported that they heard and briefly saw the aircraft flying in and out of low cloud between about 1315 and 1415. At 1348, the pilot advised ATC that the aircraft had about an hour’s endurance remaining. The pilot’s last recorded transmission was at 1404. A search for the aircraft was coordinated by Australian Search and Rescue (AusSAR). The aircraft wreckage was located on 3 October 2012, about 87 km north-west of Caboolture on the northern side of a steep, densely wooded ridge about 500 m above mean sea level. The Australian Transport Safety Bureau (ATSB) later determined that the aircraft probably impacted terrain at about 1421 on 01OCT2012. Preliminary analysis indicated that the aircraft collided with trees and terrain at a moderate to high speed, with a left angle of bank. The aircraft’s direction of travel at impact was toward the south-south-west.
Probable cause:
From the evidence available, the following findings are made with respect to the visual flight rules into instrument meteorological conditions accident involving de Havilland Aircraft Pty Ltd DH-84 Dragon, registered VH-UXG, that occurred 36 km south-west of Gympie, Queensland, on 1 October 2012. These findings should not be read as apportioning blame or liability to any particular organisation or individual. Safety issues, or system problems, are highlighted in bold to emphasize their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.
Contributing factors:
- The pilot unintentionally entered instrument meteorological conditions and was unable to reattain and maintain visual conditions.
- It is likely that the pilot became spatially disoriented and lost control due to a combination of factors such as the absence of a visible horizon, cumulative workload, stress and/or distraction.
Other factors that increased risk:
- Though it probably did not have a significant bearing on the event, the aircraft was almost certainly above its maximum take-off weight (MTOW) on take-off, and around the MTOW at the time of the accident.
- Though airborne search and rescue service providers were regularly tasked to provide assistance to pilots in distress, there was limited specific guidance on the conduct of such assistance. Other findings:
- The aircraft wreckage was not located for 2 days as the search was hindered by difficult local weather conditions and terrain, and the cessation of the aircraft’s emergency beacon due to impact damage.
Final Report:

Crash of a Rockwell Shrike Commander 500S in Clonbinane: 2 killed

Date & Time: Jul 31, 2007 at 2000 LT
Operator:
Registration:
VH-YJB
Flight Phase:
Survivors:
No
Site:
Schedule:
Melbourne – Shepparton
MSN:
500-3299
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2342
Captain / Total hours on type:
970.00
Aircraft flight hours:
4558
Circumstances:
At 1946 Eastern Standard Time on 31 July 2007, a Rockwell International Aero Commander 500S, registered VH-YJB (YJB), departed Essendon Airport, Vic. on a business flight to Shepparton that was conducted at night under the instrument flight rules (IFR). On board were the pilot and one passenger. At 1958, while in the cruise at 7,000 ft above mean sea level (AMSL) in Class C controlled airspace, radar and radio contact with the aircraft was lost simultaneously by air traffic control when it was about 25 NM (46 km) north-north-east of Essendon. The air traffic controller declared a distress phase after a number of unsuccessful attempts to contact the pilot. At 2003, the Operations Director at Melbourne Centre declared the aircraft as probably lost and advised AusSAR. A search was commenced using a helicopter and an aeroplane in addition to ground search parties. No emergency locator transmitter signal was reported. At 2147, aircraft wreckage was located by a searching aircraft in timbered ranges near Clonbinane, approximately 50 km north of Melbourne. At about 2200, a ground search party confirmed that the wreckage was that of YJB and that there were no survivors. The flight was arranged to take the company owner, who was also a licensed aircraft maintenance engineer (LAME), to Shepparton to replace an unserviceable starter motor in another of the operator‟s aircraft. The pilot, who had landed at Essendon at 1915 from a previous flight in another of the operator‟s aircraft, was tasked to fly the owner to Shepparton. The pilot transferred to YJB, which had previously been prepared for flight by another company pilot. At 1938, while taxiing for takeoff, the pilot advised the aerodrome controller of the intention to conduct the IFR flight, adding, „…and request a big favour for a submission of a flight plan, with an urgent departure Essendon [to] Shepparton [and] return‟. The aerodrome controller did not have the facilities for processing flight notifications and sought the assistance of a controller in the Melbourne air traffic control centre. There were no eyewitnesses to the accident. Residents living in the vicinity of the accident site were inside their homes and reported difficulty hearing anything above the noise made by the wind and the foliage being blown about. One of the residents reported hearing a brief, loud engine noise. Another resident thought the noise was that of a noisy vehicle on the road. The noise was described as being constant, „…not spluttering or misfiring‟ and lasted for only a few seconds. Some of those residents near the accident site reported hearing and feeling an impact only moments after the engine noise ceased. The aircraft was seriously damaged by excessive in-flight aerodynamic forces and impact with the terrain. The vegetation in the immediate vicinity of the main aircraft wreckage was slightly damaged as the aircraft descended, nearly vertically, through the trees. The pilot and passenger were fatally injured.
Probable cause:
Structural failure and damage:
From the detailed examination and study of the aircraft wreckage undertaken by ATSB investigation staff, it was evident that all principal structural failures had occurred under gross overstress conditions i.e. stresses significantly in excess of the physical strength of the respective structures. The examination found no evidence of pre-existing cracking, damage or material degradation that could have appreciably reduced the strength of the failed sections, nor was there any indication that the original manufacture, maintenance or repair processes carried out on the aircraft were in any way contributory to the failures sustained.

Breakup sequence:
From the localised deformation associated with the spar failures, it was evident that the aircraft had sustained a large negative (downward) loading on the wing structure. That downward load resulted in the localised bending failure of the wing around the station 145 position (145” outboard of the aircraft centreline). The symmetry of both wing failures and the absence of axial twisting within the fuselage section suggested that the load encountered was sudden and well in excess of the ultimate strength of the wing structure. Based upon the witness marks on both wing under-surfaces and the crushing and paint transfer along the leading edges of the horizontal stabilisers, it was concluded that after separating from the inboard structure, both wings had moved aft in an axial twisting and rotating fashion; simultaneously impacting the leading edges of both horizontal tailplanes. Forces imparted into the empennage structure from that impact subsequently produced the rearward separation of the complete empennage from the fuselage. The loss of the left engine nacelle fairing was likely brought about through an impact with a section of wing leading edge as it rotated under and to the rear. The damage sustained by all of the aircraft‟s control surfaces was consistent with failure and separation from their respective primary structure under overstress conditions associated with the breakup of the aircraft. There was no evidence of cyclic or oscillatory movement of the surfaces before separation that might have suggested the contribution of an aerodynamic flutter effects.

Findings
The following statements are a summary of the verified findings made during the progress of the aircraft wreckage structural examination and analysis:
- All principal failures within the aircraft wings, tailplanes and empennage had occurred as a result of exposure to gross overstress conditions.
- The damage sustained by the aircraft wreckage was consistent with the aircraft having sustained multiple in-flight structural failures.
- The damage sustained by the aircraft wreckage was consistent with the structural failure sequence being initiated by the symmetric, downward bending failure of both wing sections, outboard of the engine nacelles.
- Breakup and separation of the empennage was consistent with having been initiated by impact of the separated outboard wings with the leading edges of the horizontal stabilisers.
- There was no evidence of material or manufacturing abnormalities within the aircraft structure that could be implicated in the failures and breakup sustained.
- There was no evidence of service-related degradation mechanisms (such as corrosion, fatigue cracking or environmental cracking) having affected the aircraft structure in the areas of failure.
Final Report:

Crash of a Partenavia P.68B Victor off Rottnest Island

Date & Time: Nov 12, 2006 at 1500 LT
Type of aircraft:
Operator:
Registration:
VH-IYK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Rottnest Island - Perth
MSN:
138
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Rottnest Island Airport, while in initial climb, the twin engine aircraft suffered a bird strike and crashed in a salt lake located near the airport. The aircraft was destroyed upon impact and all six occupants were injured.
Probable cause:
Loss of control during initial climb following a bird strike.

Crash of a Piper PA-61 Aerostar (Ted Smith 601) off Byron Bay: 2 killed

Date & Time: Jan 27, 2004 at 1335 LT
Operator:
Registration:
VH-WRF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Coolangatta - Coolangatta
MSN:
61-0497-128
YOM:
1978
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7127
Captain / Total hours on type:
308.00
Copilot / Total flying hours:
283
Copilot / Total hours on type:
3
Circumstances:
The Ted Smith Aerostar 601 aircraft, registered VH-WRF, departed Coolangatta at 1301 ESuT with a flight instructor and a commercial pilot on board. The aircraft was being operated on a dual training flight in the Byron Bay area, approximately 55 km south-south-east of Coolangatta. The aircraft was operating outside controlled airspace and was not being monitored by air traffic control. The weather in the area was fine with a south-easterly wind at 10 - 12 kts, with scattered cloud in the area with a base of between 2,000 and 2,500 ft. The purpose of the flight was to introduce the commercial pilot, who was undertaking initial multi-engine training, to asymmetric flight. At approximately 1445, the operator advised Australian Search and Rescue that the aircraft had not returned to Coolangatta, and that it was overdue. Recorded radar information by Airservices Australia revealed that the aircraft had disappeared from radar coverage at 1335. Its position at that time was approximately 18 km east-south-east of Cape Byron. Search vessels later recovered items that were identified as being from the aircraft in the vicinity of the last recorded position of the aircraft. Those items included aircraft checklist pages, a blanket, a seat cushion from the cabin, as well as a number of small pieces of cabin insulation material. No item showed any evidence of heat or fire damage. No further trace of the aircraft was found.
Probable cause:
Without the aircraft wreckage or more detailed information regarding the behaviour of the aircraft in the final stages of the flight, there was insufficient information available to allow any conclusion to be drawn about the development of the accident. Many possible explanations exist. The fact that no radio transmission was received from the aircraft around the time radar contact was lost could indicate that the aircraft was involved in a sudden or unexpected event at that time that prevented the crew from operating the radio. The speed regime of the aircraft during the last recorded data points indicated that airframe failure due to aerodynamic overload was unlikely. The nature of the items from the aircraft that were recovered from the ocean surface indicated that the aircraft cabin had been ruptured during the accident sequence.
Final Report:

Crash of a Rockwell Grand Commander 680F near Cloncurry: 2 killed

Date & Time: Nov 9, 1994 at 1015 LT
Operator:
Registration:
VH-SPP
Flight Phase:
Survivors:
No
Schedule:
Cloncurry - Cloncurry
MSN:
680-1128-74
YOM:
1961
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
11400
Captain / Total hours on type:
710.00
Aircraft flight hours:
7546
Circumstances:
The aircraft was engaged in aero-magnetic survey operations in an area which extended from approximately 40–130 km south of Cloncurry. The task involved flying a series of north-south tie lines spaced 2 km apart at a height above ground of 80 m and a speed of 140 kts. At this speed, each tie line occupied about 20 minutes of flight time. The flight was planned to depart Cloncurry at 0700–0730 EST and was to return by 1230 to prepare data collected during the flight for transfer to the company’s head office. An employee of the operating company saw the crew (pilot and equipment operator) preparing to depart the motel for the airport at about 0500. No person has been found who saw the crew at the aerodrome or who saw or heard the aircraft depart. At about 1000, three witnesses at a mining site in the southern section of the survey area saw a twin-engine aircraft at low level heading in a northerly direction. One of these witnesses, about 1.5 hours later, saw what he believed was the same aircraft flying in an easterly direction about 1 km from his position. Between 1000 and 1030, two witnesses at a mine site some 9 km north of the survey area (and about 5 km west of the accident site) heard an aircraft flying in a north-south direction, apparently at low level. On becoming aware that the aircraft had not returned to Cloncurry by 1230, a company employee at Cloncurry initiated various checks at Cloncurry and other aerodromes in the area, with Brisbane Flight Service, and with the company’s head office later in the afternoon. At about 2030, the employee advised the company chief pilot that the aircraft was overdue. The chief pilot contacted the Civil Aviation Authority Search and Rescue organisation at about 2045 and search-and-rescue action was initiated. The burnt-out wreckage of the aircraft was found early the following morning approximately 9 km north of the survey area.
Probable cause:
For reason(s) which could not be conclusively established, the pilot shut off the fuel supply to the left engine and feathered the left propeller. For reason(s) which could not be conclusively established, the pilot lost control of the aircraft.
Final Report:

Crash of a Piper PA-31-310 Navajo near Brisbane: 1 killed

Date & Time: Jul 20, 1993 at 1546 LT
Type of aircraft:
Operator:
Registration:
VH-UFO
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Brisbane – Caboolture
MSN:
31-7712060
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
531
Captain / Total hours on type:
35.00
Circumstances:
The aircraft, with only the pilot on board, was being flown from Archerfield to Caboolture via the light aircraft lane to the west of Brisbane in company with another aircraft. About five minutes after departing Archerfield, the pilot radioed that he was experiencing problems with both engines and that he was in an emergency situation. The pilot of the other aircraft advised him that there were suitable forced landing areas in and around a nearby golf course. However, the aircraft continued and slowly lost altitude before rolling inverted and diving steeply into the ground. Ground witnesses reported hearing loud backfiring and fluctuating engine RPM from the aircraft. These sounds were accompanied by erratic rolling and yawing of the aircraft before it rolled to the left and inverted. The right wing was severed outboard of the engine as the aircraft impacted a large tree before crashing onto a road.
Probable cause:
Wreckage examination revealed that the fuel selectors for both engines were set at the auxiliary tank positions, causing fuel for each engine to be drawn from the corresponding auxiliary tank in each wing. It was established that the aircraft had been refuelled to full main tanks prior to the flight. Further, the pilot had advised in a telephone conversation with an engineer before the flight that the contents of both auxiliary tanks was 60 litres or less. All fuel tanks except the left auxiliary tank were ruptured during the impact sequence. About one litre of fuel was recovered from this
tank. Examination of the aircraft engines indicated that the right engine was under power at impact while the left engine was not. The mechanical condition of the engines indicated that they were capable of normal operation.
The following factors are considered relevant to the development of the accident:
- The pilot did not use a written checklist.
- The pilot operated the aircraft with the auxiliary tanks selected when the fuel contents of these tanks was low.
- The pilot failed to conduct a forced landing.
Final Report: