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Crash of a Cessna 402C in Bundaberg: 4 killed

Date & Time: Jun 21, 1987 at 0318 LT
Type of aircraft:
Operator:
Registration:
VH-WBQ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Bundaberg - Brisbane
MSN:
402C-0627
YOM:
1982
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The flight had been arranged to transport a critically injured patient to hospital in Brisbane. The pilot evidently experienced some difficulty in starting one of the engines. However, witnesses reported that the engines sounded normal as the aircraft commenced moving from the parking area. At 0310 hours the pilot contacted Brisbane Flight Service Unit and reported that the aircraft was taxying. He advised that he was in a hurry, and indicated that he would provide details of the flight after takeoff. Two minutes later he advised that takeoff was being commenced from Runway 14. No further transmissions were received from the aircraft. The aircraft was seen to become airborne and shortly afterwards enter a fog bank. Other witnesses subsequently reported hearing the sounds of an impact. The flight had been arranged to transport a critically injured patient to hospital in Brisbane. The pilot evidently experienced some difficulty in starting one of the engines. However, witnesses reported that the engines sounded normal as the aircraft commenced moving from the parking area. At 0310 hours the pilot contacted Brisbane Flight Service Unit and reported that the aircraft was taxying. He advised that he was in a hurry, and indicated that he would provide details of the flight after takeoff. Two minutes later he advised that takeoff was being commenced from Runway 14. No further transmissions were received from the aircraft. The aircraft was seen to become airborne and shortly afterwards enter a fog bank. Other witnesses subsequently reported hearing the sounds of an impact. The flight had been arranged to transport a critically injured patient to hospital in Brisbane. The pilot evidently experienced some difficulty in starting one of the engines. However, witnesses reported that the engines sounded normal as the aircraft commenced moving from the parking area. At 0310 hours the pilot contacted Brisbane Flight Service Unit and reported that the aircraft was taxying. He advised that he was in a hurry, and indicated that he would provide details of the flight after takeoff. Two minutes later he advised that takeoff was being commenced from Runway 14. No further transmissions were received from the aircraft. The aircraft was seen to become airborne and shortly afterwards enter a fog bank. Other witnesses subsequently reported hearing the sounds of an impact. The investigation revealed that the aircraft had collided with a tree 800 metres beyond the aerodrome boundary, while tracking about 10 degrees to the right of the extended centreline of the runway. It had then continued on the same heading until striking the ground 177 metres beyond the initial impact point. The wreckage was almost totally consumed by fire.
Probable cause:
The extensive fire damage hampered the investigation of the accident. The surviving passenger believed that the aircraft was on fire before the collision with the tree. No other evidence of an in-flight fire could be obtained, and it was considered possible that the survivor's recall of the accident sequence had been affected by the impact and the fire. Such discrepancies in recall are not uncommon among accident survivors. The elevator trim control jack was found to be in the full nose-down position, but it was not possible to establish whether the trim was in this position prior to impact. Such a pre-impact position could indicate either a runaway electric trim situation or that, in his hurry to depart, the pilot had not correctly set the trim for takeoff. The aircraft was known to have had an intermittent fault in the engine fire warning system. The fault apparently caused the fire warning light to illuminate, and the fire bell to sound, usually just after the aircraft became airborne. The pilot was aware of this fault. It was considered possible that, if the fault occurred on this occasion as the aircraft entered the fog shortly after liftoff, the pilot's attention may have been focussed temporarily on the task of cancelling the warnings. During this time he would not have been monitoring the primary flight attitude indicator, and would have had no external visual references. It was also possible that, if for some reason the pilot was not monitoring his flight instruments as the aircraft entered the fog, he suffered a form of spatial disorientation known as the somatogravic illusion. This illusion has been identified as a major factor in many similar accidents following night takeoffs. As an aircraft accelerates, the combination of the forces of acceleration and gravity induce a sensation that the aircraft is pitching nose-up. The typical reaction of the pilot is to counter this apparent pitch by gently applying forward elevator control, which can result in the aircraft descending into the ground. In this particular case, the pilot would probably have been more susceptible to disorientating effects, because he was suffering from a bronchial or influenzal infection. Although all of the above were possible explanations for the accident, there was insufficient evidence available to form a firm conclusion. The precise cause of the accident remains undetermined.
It is considered that some of the following factors may have been relevant to the development of the accident
1. The pilot was making a hurried DEPARTURE. It is possible that he did not correctly set the elevator trim and/or the engines may not have reached normal operating temperatures before the takeoff was commenced.
2. Shortly after liftoff the aircraft entered a fog bank, which would have deprived the pilot of external visual references.
3. The aircraft had a defective engine fire warning system. Had the system activated it may have distracted the pilot at a critical stage of flight.
4. The aircraft might have suffered an electric elevator trim malfunction, or an internal fire, leading to loss of control of the aircraft.
5. The pilot may have experienced the somatogravic illusion and inadvertently flown the aircraft into the ground. The chances of such an illusion occurring would have been increased because the pilot was evidently suffering from an infection.
Final Report:

Crash of a Piper PA-31-310 Navajo in Cairns: 8 killed

Date & Time: Sep 2, 1986 at 1408 LT
Type of aircraft:
Operator:
Registration:
VH-CJB
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Cairns - Mount Isa
MSN:
31-249
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
The pilot hired the aircraft privately from his employer to conduct a holiday flight during his leave. The journey commenced at Moorabbin on 25 August and the aircraft arrived at Cairns about midday 30 August, after stopovers at Coolangatta and Proserpine. The pilot and his passengers then spent the next three days at leisure in the Cairns area. On the day of the accident, the pilot attended the Cairns Briefing Office where he collected the relevant weather forecasts and submitted a flight plan. The flight plan indicated that the flight would be conducted in accordance with Instrument Flight Rules. It contained a deficiency in that no details were given for the first route segment from Cairns to Biboohra. It is apparent that the pilot had not noticed that the tracks to the west of Cairns, on the relevant enroute chart, emanate from Biboohra and not Cairns. There was no track line which joined Cairns and Biboohra. Such a line might have alerted the pilot at the time he planned the flight. The error in the flight plan was not detected when the plan was submitted. When the pilot was issued with an airways clearance prior to DEPARTURE it was apparent that he did not understand the terms of the clearance, which gave the initial tracking point as Biboohra. The location of this point was explained to the pilot and he subsequently accepted the clearance. He elected to depart using visual procedures, after being offered a choice of these or the published Standard Instrument DEPARTURE profile. A visual DEPARTURE from the particular runway in use allows an aircraft proceeding towards Biboorha to intercept the required track sooner than is possible with an instrument DEPARTURE. The aircraft was issued with takeoff instructions which included clearance for the pilot to make a right turn after takeoff. Witnesses observed that the aircraft complied with this clearance and headed in a southwesterly direction before turning to the north-west and subsequently entering cloud. The cloud base was estimated to be between 2000 and 2500 feet above mean sea level. No further communications were received from the aircraft and a search was commenced that afternoon. The search effort was hampered by the weather and the wreckage was not located until the following afternoon.
Probable cause:
Inspection of the wreckage indicated that the aircraft struck the the top of a ridge line, 250 metres south-west of the highest point of the Mt Williams area. At the time, the aircraft was on a west-north-westerly heading, flying wings level and climbing at a angle of about five degrees. No fault was found with the aircraft that could have contributed to the occurrence. At the time the aircraft entered cloud, the pilot should have reverted to Instrument Flight Rules procedures. To comply with these procedures a pilot is required, inter alia, to ensure that adequate terrain clearance is achieved during climb to the lowest safe altitude. The relevant altitude for the route segment Cairns to Biboohra is 4500 feet above mean sea level (amsl). As the aircraft was apparently under control at the time of impact with the ground at about 3250 feet amsl, it was likely that the pilot had overlooked the lowest safe altitude requirements.
Final Report:

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

Date & Time: Jul 16, 1986 at 1818 LT
Type of aircraft:
Operator:
Registration:
VH-UCK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Benalla – Bankstown
MSN:
31-7712029
YOM:
1977
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
At the time of the attempted take-off, the night was dark, with overcast cloud conditions and light rain falling. Wind conditions were light and variable. The pilot reported that initial acceleration was normal, and the aircraft became airborne at about 95 knots. A positive rate of climb was established and the landing gear was selected up. The pilot subsequently advised that the speed then decayed to 90 knots. At this time there was nothing unusual in the engine noise and the controls felt normal. Shortly afterwards the propellers struck the ground 116 metres beyond the end of the runway. The aircraft then struck an embankment and passed through a fence before coming to rest 247 metres from the initial ground strike. All four occupants escaped with minor injuries and the aircraft was destroyed.
Probable cause:
Although wind conditions were light and variable when the engines were started, shortly after the accident the wind was moderate from the west/south-west. A detailed analysis conducted by the Bureau of Meteorology indicated that while the pilot was preparing for take-off, a cold front with winds in excess of 20 knots had probably passed over the aerodrome. As the pilot had conducted the take-off on runway 08, there was probably a substantial tailwind component. Conditions were also assessed as suitable for the development of microbursts, but the lack of recording instruments in the area prevented confirmation that this type of phenomenon had in fact occurred. The pilot had been deprived of the opportunity to observe changing wind conditions at the aerodrome. The wind direction indicator adjacent to the threshold of runway 08 was not lit, and the illuminated wind direction indicator was not visible from the point where the aircraft was lined up for take-off.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601B) in Lismore: 1 killed

Date & Time: Mar 11, 1986 at 1659 LT
Operator:
Registration:
VH-CUO
Flight Type:
Survivors:
No
Schedule:
Coolangatta – Lismore
MSN:
61-0806-8062151
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
When the aircraft arrived in the destination area, another aircraft was also in the circuit. The pilots were in communication with each other, and arranged that VH-CUO would land after the other aircraft. However, the pilot of VH-CUO apparently misjudged the relative speeds of the two aircraft. He initiated a go-around from a position on final approach to runway 15, when there was evidently insufficient separation with the preceding aircraft to allow a normal landing. The aircraft remained at a low height above the ground, and the pilot broadcast a message that he intended to land in the opposite direction, on runway 33. The wind at the time was from the south-east at about 10 knots. Witnesses observed the aircraft as it tracked along the western side of the runway. The turn onto base leg was made at an angle of bank of about 60 degrees, and about three-quarters of the way around the turn, the nose of the aircraft dropped rapidly. The aircraft then dived steeply to the ground, and was destroyed by the impact and subsequent fire.
Probable cause:
The subsequent investigation did not reveal any defect or malfunction which might have affected the operation of the aircraft. The pilot was conducting an operation known as a "bank run", and there is pressure on pilots performing such runs to adhere to the prescribed schedules. The pilot's decision to perform a low level circuit and land downwind was considered to be related to his desire to arrive at the terminal as close as possible to the scheduled time. While conducting the circuit, the aircraft stalled during a turn at a height which was too low to allow the pilot to recover control before impact with the ground.
Final Report:

Crash of a Partenavia P.68B Victor near Adelaide: 2 killed

Date & Time: Nov 9, 1985
Type of aircraft:
Operator:
Registration:
VH-YIH
Flight Phase:
Flight Type:
Survivors:
No
MSN:
134
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Crashed in unknown circumstances in an open field located about 80 km south of Adelaide and burnt. Both occupants were killed.

Crash of a Cessna 340A in Goulburn: 4 killed

Date & Time: May 16, 1984 at 2304 LT
Type of aircraft:
Operator:
Registration:
VH-BYB
Flight Type:
Survivors:
No
Site:
Schedule:
Sydney - Goulburn
MSN:
340A-0411
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
Prior to departure the pilot had received a weather forecast which indicated that fog could be expected at the destination. Adequate fuel was carried in the aircraft tanks to allow for a considerable period of holding and/or a diversion to another aerodrome if required. After an apparently normal flight of 35 minutes the aircraft arrived in the Goulburn area and the pilot reported his intention to carry out a standard instrument approach. The manoeuvres associated with this procedure do not involve flight over the city of Goulburn, however witnesses observed the aircraft as it circled over the city several times at a relatively low height. It was then seen to roll and descend steeply before striking two houses. A fierce fire broke out which engulfed the aircraft and both residences. The three persons on board the aircraft and a person in one of the houses received fatal injuries. A detailed inspection of the wreckage revealed that the camshaft of the left engine had failed in flight and the pilot had apparently feathered the propeller. The engine was not operating at the time of impact. No other defect or malfunction was discovered which might have contributed to the development of the accident. It was determined that the particular camshaft had failed from fatigue cracking, resulting from defective manufacture. It was considered likely that when the aircraft arrived over Goulburn, shallow fog obscured all or part of the aerodrome. The lights of the city would have been clearly visible and the pilot probably decided to use the city, rather than the nearby radio navigation aid, as a convenient holding point while waiting for conditions at the aerodrome to improve. During a series of left hand orbits, and after advising his intention to conduct an instrument approach, the pilot experienced a complete failure of the left engine. In order to realise the available single-engine performance of the aircraft the pilot had to perform a series of checks and actions which would result in the applicable propeller being feathered; any unnecessary aerodynamic drag being reduced; and an appropriate airspeed being established. It was determined that although the propeller had probably been feathered, the landing gear, which had evidently been lowered previously, had not been raised to reduce drag. In addition, an analysis of radar returns from the aircraft, recorded at Canberra, indicated that the airspeed at which the aircraft was flying shortly before radar contact was lost, was less than the optimum figure. The final manoeuvre described by witnesses was consistent with that which follows a loss of control in twin engine aircraft when power is being supplied by only one engine and the speed is below the minimum required for full control. The reason the pilot did not raise the landing gear and maintain the required minimum control speed could not be established.
Probable cause:
Failure of the left engine in flight due to defective manufacture of camshaft. The following contributing factors were reported:
- Fatigue failure of camshaft,
- Complete loss of power from left engine,
- Aircraft not reconfigured for optimum single engine performance,
- Airspeed fell below minimum for effective control,
- Insufficient height for recovery.
Final Report:

Crash of a Fletcher FU-24 in Stuart Mill

Date & Time: Feb 25, 1984 at 1557 LT
Type of aircraft:
Operator:
Registration:
VH-EOF
Flight Phase:
Survivors:
Yes
Schedule:
Stuart Mill - Stuart Mill
MSN:
2
YOM:
1954
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after take-off during a spreading operation the engine suddenly lost power. The pilot dumped the load and operated the fuel boost pump, however after a short burst of power the engine failed completely. The pilot was committed to a downwind landing and towards the end of the landing roll the aircraft ran into a gully and collided with tree stumps. The aircraft was damaged beyond repair and the pilot was slightly injured.
Probable cause:
The engine had failed from fuel exhaustion. The pilot was not aware of the amount of fuel added to the tanks at the previous refuelling and he had subsequently relied on the fuel gauge readings to assess the remaining endurance.
Final Report:

Crash of a Rockwell Aero Commander 685 near Ben Lomond: 1 killed

Date & Time: Jan 20, 1984 at 0825 LT
Operator:
Registration:
VH-MML
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Armidale – Glen Innes
MSN:
685-12054
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
During the flight the pilot reported that he would descend to cruise at 500 feet above ground level. Witnesses saw an aircraft at low level on the expected track, and others heard aircraft noise and then the sound of an impact. Weather conditions were overcast with low cloud covering the hills. The wreckage was found at an elevation of about 4,300 feet above mean sea level. The aircraft had apparently struck the ground while in a steep nosedown attitude and rotating to the right. A fire had broken out and engulfed the wreckage. The pilot, sole on board, was killed.
Probable cause:
Investigation did not reveal any defect or malfunction of the aircraft which might have contributed to the development of the accident. Both engines were operating at high power settings and the gear and flaps were up. The aircraft had been operating under the Instrument Flight Rules when the pilot reported his intention to descend. Conditions at the destination were suitable for visual flight, and the reason the pilot elected to proceed at a low height above the ground was not determined. It was likely that while cruising below the cloud, the pilot was suddenly confronted by localised adverse weather conditions in the vicinity of the accident site. The maintenance of control of the aircraft under these conditions should have presented little problem to the pilot, who was suitably qualified to operate in instrument conditions. In these circumstances, the precise sequence of events leading to the evident loss of control of the aircraft could not be established.
Final Report:

Crash of a Rockwell Aero Commander 685 in the Bass Strait: 2 killed

Date & Time: Jul 17, 1983 at 1505 LT
Operator:
Registration:
VH-WJC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hobart - Melbourne
MSN:
685-12005
YOM:
1972
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
On 17 July 1983 the pilot of Rockwell (Aero Commander) 685 aircraft VH-WJC submitted a flight plan to the Hobart Briefing Office for a private category flight from Hobart to Moorabbin, tracking via Launceston and Wonthaggi. The plan indicated that the flight would be conducted under the Instrument Flight Rules (IFR) at Flight Level 120 (12 000 feet altitude on standard atmospheric pressure of 1013.2 millibars), with two persons on board. The flight plan showed that the aircraft had a fuel endurance of 220 minutes, and carried an Emergency Locator Beacon (ELB) and life jackets. There was no indication that a life raft was carried. The aircraft departed Hobart at 1352 hours and, thereafter, the pilot made the appropriate radio reports to Hobart Tower, Launceston Control and Launceston Tower. The flight apparently progressed normally until 1452 hours when the pilot advised Launceston Control, "Er Whiskey Juliet Charlie we seem to have been in trouble with er fuel here the red er warning light comes on and the gauge is down . . .".At 1454 hours the pilot transmitted a Mayday call, indicating that he was descending from Flight Level 120 on track to Bass (a position reporting point), present position was 85 nautical miles (nm) from Launceston and he would be making a controlled ditching. Launceston Control immediately initiated the Distress phase of the Search and Rescue procedures and advised the Melbourne Operational Control Centre (OCC). Further communications between the aircraft and Launceston Control indicated that the aircraft was continuing descent on track towards Wonthaggi. The last position report from the pilot, at 1500 hours, was 94 nm from Wonthaggi. The last recorded transmission from the aircraft was at 1501 hours when the pilot confirmed that there were two persons on board. There were no indications at any time from the pilot that the fuel supply had been exhausted or that either engine had failed. It was estimated that the aircraft ditched at about 1505 hours, at an approximate position of 81 nm from Wonthaggi on the planned track. No trace of the aircraft nor both occupants was found.
Probable cause:
Due to lack of evidences, the exact cause of the accident could not be determined.
Final Report:

Crash of a Fletcher FU-24 in Yass

Date & Time: Dec 31, 1980
Type of aircraft:
Operator:
Registration:
VH-EOA
Flight Phase:
Survivors:
Yes
MSN:
43
YOM:
1957
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances in Yass while engaged in a crop spraying mission. The pilot, sole on board, was injured.