Country
code

Western Australia

Crash of a Lockheed P-3C Orion off Cocos Islands: 1 killed

Date & Time: Apr 26, 1991
Type of aircraft:
Operator:
Registration:
A9-754
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
185-5662
YOM:
1978
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft was engaged in a local flight and was carrying 17 passengers and a crew of four. After takeoff from Cocos Island Airport, the crew climbed to 5,000 feet then reduced his altitude for a low pass over the airport. Approaching the airport at a speed of 380 knots and at a height of about 300 feet, the pilot-in-command increased engine power in a way to gain height when the aircraft lost several pieces from the left wing. Due to severe vibrations and problems of controllability, the crew decided to attempt an emergency landing near the airport. The aircraft struck the ground, lost its undercarriage and came to rest in shallow water. A passenger was killed after being hit by propeller blades that punctured the fuselage. All 20 other occupants escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
Forced landing following severe vibrations after several elements from the left leading edge detached in flight.

Crash of a Mitsubishi MU-2B-60 Marquise near Meekatharra: 2 killed

Date & Time: Jan 26, 1990 at 0105 LT
Type of aircraft:
Registration:
VH-MUA
Flight Phase:
Survivors:
No
Schedule:
Perth - Port Hedland
MSN:
746
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
11030
Captain / Total hours on type:
51.00
Aircraft flight hours:
1902
Circumstances:
The aircraft had been chartered for a flight from Perth to Port Hedland. The pilot arrived at the aircraft at 2210 hours on 25 January, and after a short inspection of the aircraft, attended the CAA flight planning office for air traffic control and meteorology briefing. The briefing included information about a tropical cyclone off the NW coast of Australia and its potential effects on the proposed flight. After the flight plan was submitted, the pilot returned to the aircraft at 2315 hours as the loading was being completed, and conducted a preflight inspection of the aircraft and its load. The aircraft departed Perth at 2339 and commenced a climb towards Ballidu, the first turning point, over which it passed at 0003 hours. Subsequently, the aircraft passed over Mt Singleton at 0020, Mt Magnet at 0040 and Meekatharra at 0102 hours. After Ballidu, the aircraft climbed from FL170 to FL190 and climbed further to FL210 after Mt Magnet. While over Meekatharra, the passenger (also a licenced pilot) gave the position report. One minute later, the pilot radioed that the aircraft was out of control and descending. He called again 30 seconds later and advised that the aircraft was in ice and spinning down through 8,000 feet. No further communications were received from the aircraft. Both occupants were killed.
Probable cause:
The following findings were reported:
- The pilot did not have recent experience in high-performance, high-altitude aircraft except for the 51.7 hours gained in the MU-2.
- The pilot did not possess some of the experience levels and recency requirements placed on MU-2 pilots immediately after the accident by the CAA.
- The pilot did not take sufficient account of the operational characteristics of this aircraft type.
- The pilot's situational awareness was probably impaired during the flight, because of the combination of pre-existing cumulative fatigue, and insufficient sleep in the previous 42 hours.
- The meteorological conditions were conducive to the formation of airframe icing on an aircraft flying in cloud along the flight planned route.
- It is probable that control was lost as the aircraft banked to the left over Meekatharra, to change track towards Port Hedland.
- The pilot reported that the aircraft was in ice during his last radio transmission.
- The pilot was unable to recover from the spin before the aircraft hit the ground.
Final Report:

Crash of a Piper PA-31-310 Navajo in Carnarvon

Date & Time: Aug 18, 1989 at 1856 LT
Type of aircraft:
Operator:
Registration:
VH-DEG
Flight Type:
Survivors:
Yes
Schedule:
Geraldton – Carnarvon
MSN:
31-7812098
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
At approximately 1809, (23 minutes before last light) during final approach to landing at Carnarvon, the pilot noticed that the landing gear had not extended correctly. The aircraft remained in the circuit area whilst the pilot attempted to lower the landing gear using both manual and emergency methods. He also sought assistance from the company's, Perth based, duty pilot and Carnarvon based engineers. After exhausting all possible methods of lowering the gear the pilot decided to land with the landing gear and flaps retracted. The pilot rejected a landing on the sealed runways because he was apprehensive that it would cause unnecessary damage to the aircraft and could result in a fire. He considered landing in a riverbed (rejected by the Senior Operational Controller), alongside one of the sealed runways (the surface was unsuitable) and on one of the dirt strips. The pilot was offered a flare path on dirt runway 27 however, he declined and indicated that he would try to land using the available light. At 1856 (last light was at 1832) the pilot attempted a landing on runway 27. On late final approach the aircraft collided with a one and a half metre high levy bank, 270 metres short and 115 metres to the right of the threshold. The pilot was trapped in the wreckage for some time after the aircraft came to a stop. While the passenger was slightly injured, the pilot was seriously wounded.
Probable cause:
The landing gear problem arose when the left main landing gear would not lower. Examination of the aircraft revealed that both hinges fitted to the inboard landing gear door had fractured. The forward hinge had fractured as a result of fatigue and the rear hinge as a result of overload. The fatigue crack initiation had occurred at a sharp edged, prominent forging flash on the inner radius of the hinge and had grown over approximately 4000 load cycles. A similar fatigue problem had been identified on an earlier version of the hinge (part number 46653-00), however, regular inspections for fatigue cracking were discontinued when hinges with part number 47529-32 (as fitted to VH-DEG) were introduced in 1980. Similar fatigue cracking was found in the forward door hinge of another PA31 during the investigation. The fractured hinges jammed the left main landing gear mechanism and neither the normal or emergency extension systems could extend the gear. The pilot was apprehensive about wheels up landings. Much of his decision making was aimed at reducing the risk of fire and minimising the damage the aircraft would sustain during the landing. eg. Selection of a dirt runway instead of the sealed strip, landing with flaps retracted etc. During the pilot's attempts to rectify the landing gear problem, and up until the time of his touchdown, he was subjected to considerable radio transmission traffic involving questions, directions and suggestions which distracted him from his primary tasks. The pilot indicated on at least two occasions that he was ready to land, however, each time advice and questions from the ground personnel involved overrode his intentions. When the pilot was asked if he wanted a flare path on runway 27 there was still some natural light available and he was intending to land. However, by the time he was able to make his final approach it was dark and he was unable to see the ground. Studies have shown that aircrew subjected to high levels of stress can suffer skill fatigue and cognitive task saturation, which in turn can lead to a breakdown in the decision making process. It was apparent from the pilot's radio transmissions and the quality of the decisions made in the latter part of the flight that his information processing and decision making abilities had been degraded by the stress of continuous radio transmissions and continuous, and sometimes conflicting, instructions. As a result, what should have been a relatively simple wheels up landing in daylight was turned into an extremely difficult wheels up landing at night. With the landing gear retracted the aircraft's taxi and landing lights were not available to the pilot.
The following factors were considered relevant to the development of the accident:
1. Manufacturing defect. A forging flash created a stress concentration which led to fatigue cracking.
2. Inadequate inspection procedures. Previous inspection procedures introduced to disclose similar cracking were withdrawn on the introduction of later part numbered hinges.
3. Apprehension of the pilot. The pilot was apprehensive about apparently significant dangers of landing an aircraft, wheels up, on a sealed runway.
4. Inordinate interference in aircraft operations by ground based advisors. The ground advisors input overrode the pilot's decision on a number of occasions with the result that a simple exercise became very complicated.
5. Cognitive task saturation and skill fatigue. The amount of information, advice and suggestions being passed via the radio communications system overloaded the pilot decision making abilities.
6. Improper in-flight decisions. As a result of task saturation the final decision made by the pilot to attempt a night landing on an unlighted strip was incorrect.
7. The pilot did not see and therefore was unable to avoid the levy bank.
Final Report:

Crash of a Britten-Norman BN-2A-26 Islander off Derby

Date & Time: May 22, 1989 at 1350 LT
Type of aircraft:
Registration:
VH-BSN
Flight Phase:
Survivors:
Yes
Schedule:
Cockatoo Island - Derby
MSN:
3005
YOM:
1982
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot had planned the direct track for the flight from Cockatoo Island to Derby at 5,500 feet above sea level. When the pilot gave his DEPARTURE call he amended his cruising level to below 5,000 feet. No further calls were received from the aircraft. The Cockatoo Island workboat was 56 kilometres north-north-west of Derby, and approximately 20 kilometres west of the direct track between Cockatoo Island and Derby. The crew of the boat observed an aircraft approaching at very low level. The aircraft passed over the boat approximately 5-7 metres above the deck, and entered a right hand turn. During the turn the right wing tip struck the water causing the aircraft to cartwheel and crash about 400 metres from the boat. The fuselage broke open on impact and the occupants were subsequently rescued by the crew of the boat.
Probable cause:
The pilot declined to provide any information which might have clarified the circumstances of the accident, however, available information indicates that he carried out an unauthorized low pass over the boat. During the turn following the low pass, he misjudged the aircraft's height and the right wing tip struck the water.
The following factors were considered relevant to the development of the accident:
- The pilot was neither trained nor authorized to conduct operations at low level,
- The pilot exercised poor judgement by operating at an unnecessarily low height,
- The pilot misjudged his height above the water.
Final Report:

Crash of a Mitsubishi MU-2B-60 Marquise in Sturt Meadows Station: 10 killed

Date & Time: Dec 16, 1988 at 1015 LT
Type of aircraft:
Registration:
VH-BBA
Flight Phase:
Survivors:
No
Schedule:
Perth – Bellevue Mine – Kalgoorlie – Leinster – Nevoria Mine
MSN:
782
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
20
Captain / Total flying hours:
6249
Captain / Total hours on type:
134.00
Aircraft flight hours:
2827
Circumstances:
The aircraft had been chartered for a return flight from Perth to Bellevue Mine, Kalgoorlie and Nevoria Mine. The aircraft departed Perth on 15 December and arrived at Bellevue Mine after an uneventful flight. The following morning the pilot telephoned Kalgoorlie Flight Service Unit (FSU) and obtained brief details of expected winds for the flight to Kalgoorlie, as well as a forecast of the weather for the aircraft's arrival. He then submitted details of the flight to the flight service officer (FSO), at the same time commenting that there was some adverse weather in the Bellevue Mine area. The flight plan indicated that the pilot intended to climb to flight level (FL) 195 after take-off, with a time interval of 27 min to pass Leonora and a further 22 min to reach Kalgoorlie. The flight plan was amended after take-off to include a brief stop at Leinster. At 0940 hours the aircraft departed for Leinster, 5 km from Bellevue Mine. (This short flight was conducted to pick up passenger baggage.) At 0957 hours the pilot reported to the Kalgoorlie FSU that the aircraft had departed Leinster at 0955 hours and was climbing to FL 195. At 1008 hours he requested traffic information for a climb to FL 210 and, after being advised that there was no traffic, replied that he was climbing to that level. He also remarked that there were some big clouds in the area. No further communications were received from the aircraft. At approximately 1015 hours the aircraft crashed on Sturt Meadows Station. The crash site was approximately 1200 ft above sea level. All 10 occupants were killed.
Probable cause:
It is probable that the pilot did not have an adequate understanding of the operations of the MU-2B-60 aircraft at high altitude. The meteorological conditions were conducive to the formation of ice on aircraft flying in cloud above the freezing level. It is probable that loss of control occurred above the freezing level on climb to an amended altitude of FL 210.
Final Report:

Crash of a Rockwell Shrike Commander 500S near Canning Dam: 2 killed

Date & Time: Feb 27, 1986 at 0807 LT
Operator:
Registration:
VH-SDO
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Jandakot - Jandakot
MSN:
500-3263
YOM:
1976
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The flight was planned to check the onboard survey equipment. After departing Jandakot the aircraft operated to the south of the airfield for about 80 minutes before the pilot advised that he would be extending his operation to the east over the Darling Ranges. The aircraft was then sighted, by several witnesses, over the foothills heading in an easterly direction. These witnesses reported that the engines were not operating normally. A short time later, the aircraft was observed to pass over the dam wall at an altitude of about 25 feet and head down a valley in a northerly direction before disappearing from sight. An inspection of the wreckage indicated that the aircraft had collided with two 30 metre high trees, in a nose high attitude at a low forward airspeed, before falling to the ground below the trees. At impact neither engine was delivering power. The fuel system, which was found to be relatively intact, contained only nine litres of fuel.
Probable cause:
It was determined that the engines failed due to fuel starvation following the exhaustion of the useable fuel onboard the aircraft. The pilot was then faced with attempting a landing in unsuitable
terrain. Evidence indicates that the aircraft departed Jandakot with both the fuel quantity indicating systems unserviceable. Although the maintenance documentation for the aircraft did not indicate that these systems were unserviceable, it is believed that the pilot was aware of the maintenance state of the aircraft before departure.
Final Report:

Crash of a Piper PA-31-310 Navajo in Mount Augustus

Date & Time: Jul 4, 1981
Type of aircraft:
Operator:
Registration:
VH-DEE
Flight Type:
Survivors:
Yes
Schedule:
Carnarvon - Mount Augustus
MSN:
31-8012072
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed Carnarvon on an ambulance flight to Mount Augustus to evacuate a sick child. On board were one nurse and one pilot. The approach to Mount Augustus was initiated in limited visibility due to a moonless night and six vehicles were dispatched on the ground with lights on. While turning on final, the airplane was too low, struck trees and crashed. Both occupants were injured and the aircraft was destroyed.

Crash of a Piper PA-31T Cheyenne II in Perth: 1 killed

Date & Time: May 3, 1981 at 1125 LT
Type of aircraft:
Operator:
Registration:
VH-CCW
Flight Type:
Survivors:
No
Site:
Schedule:
Jandakot - Perth
MSN:
31-7720046
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:
4279
Captain / Total hours on type:
576.00
Circumstances:
The aircraft was flown from Jandakot to Perth at approximately 08:00 hours on 3.5.81. However, the engineer who had agreed to meet the pilot sent a message that he could not attend. At times during the morning, persons observed the aircraft parked at the airport. The engine cowls had been removed and the pilot was seen to be working in the area of the propeller governors. At about 11:00 hours, the pilot started the aircraft's engines, taxied to a clear area and carried out a series of checks" at high power. Then, at 11:09 hours, he contacted Perth Surface Movement Control by radio and requested clearance for an air test at Flight Level 200. This was approved and the aircraft was instructed to taxi to Runway 20. After take-off, the aircraft turned right and tracked to the west on the 270 radial of the VHF omni-directional radio range (VOR), in accordance with departure instructions give n by Perth Tower. When asked for his intentions, the pilot advised that he wished to continue tracking to the west until further notice. Weather conditions in the Perth area were fine; there was no cloud and the surface wind was a light southwesterly. The aircraft as it climbed out appeared to be operating normally , except for a thin smoke trail which was observed coming from the right engine. At 11:19 hours, the pilot advised that his test was completed. He reported he was at 7,000 feet and 10 miles from the airport by distance measuring equipment (DME). During the next five minutes there were a series of routine exchanges between VH-CCW and Perth Tower as the aircraft was cleared to track visually, north of Perth city, to a right base position for Runway 20. During these exchanges the pilot did not indicate that any abnormality or emergency existed and his voice sounded normal. At 11:24 hours, he reported at right base and was cleared to land. The final transmission received from the aircraft was the usual acknowledgement of the landing clearance. The right base position for Runway 20 is over the suburb of Bassendean and local residents are used to aircraft overflying. However, attention was drawn to VH-CCW as it was lower than normal traffic, the engine noise was louder and smoke was trailing from its right engine. Otherwise, it appeared to be operating normally; both propellers were rotating and the landing gear was reported to be retracted. The aircraft had commenced an apparently normal right base turn when it suddenly rolled inverted. The nose of the aircraft may have pitched up just before the sudden roll. The aircraft then began to rotate and rapidly descend. At some stage, it rolled back to the normal upright attitude. After about two turns, the rotation stopped and the aircraft dropped vertically to the ground in the backyard of a private house. The left wing and tailplane struck the roof of the house just prior to ground impact. An intense fire immediately broke out and consumed most of the wreckage. Subsequent examination of the wreckage found no evidence of pre-existing defects or malfunctions, apart from loose attachment nuts on the left side of the propeller governor fitted to the right engine. Oil had leaked from the governor at this position, covering the engine and causing the smoke trail observed by witnesses. Internal inspection of the right engine established that all bearing surfaces were oil-wetted, but it could not be determined how much oil remained in the engine at the time of ground impact as any residual oil had leaked and been consumed by fire. Both engines had been operating at impact. The right engine was at a low power setting, probably idle. The left engine was at a higher power, although the exact power setting could not be determined. The left propeller was at a blade angle consistent with higher power output. The right propeller was at a blade angle outside the normal operating range but consistent with the propeller moving towards the feather position, either as a result of pilot selection or exhaustion of the engine oil supply. It was not possible to determine whether or not the pilot had initiated feathering. The stability augmentation system servo was at the maximum, elevator-down spring tension position. The automatic system would drive the servo to this position when the aircraft was flown at low airspeed. The elevator trim was set at 10 degrees nose-up, also consistent with low-speed flight. The rudder trim was at the full-left rudder position, indicating that the pilot had been operating the aircraft for some time with high power on the left engine and the right engine at a low power setting. The flaps were half extended and the landing gear was down at ground impact. Post-mortem examination found that the pilot had extensive coronary artery disease, such that he may have suffered a sudden incapacitating attack or death. Alternatively, he may have experienced severe chest pain, causing him to unintentionally apply coarse movements to the aircraft controls. The pilot had completed regular medical examinations for the renewal of his pilot's licence, but his condition had not been detected.
Probable cause:
The exact cause of the accident could not be determined with certainty. However, the following defect was discovered: two nuts attaching the propeller governor to the right engine were loose, permitting oil to leak from the governor.
Final Report:

Crash of a Piper PA-31-310 Navajo Chieftain in Kalgoorlie: 4 killed

Date & Time: Apr 30, 1981 at 1844 LT
Type of aircraft:
Operator:
Registration:
VH-KMS
Flight Type:
Survivors:
Yes
Schedule:
Jameson - Kalgoorlie
MSN:
31-7712056
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
22655
Captain / Total hours on type:
500.00
Circumstances:
The pilot acted as a relief pilot for the Eastern Goldfields Section of the Royal Flying Doctor Service based in Kalgoorlie. On 30 April 1981 he had been rostered as the duty pilot from 1100 hours to 1700 hours. He was advised by the chief pilot soon after 1100 hours that a flight to Jameson and return was required. The flight was planned to include a refuelling stop at Warburton en-route to Jameson. The pilot expressed concern that the flight might not be completed in daylight, but after discussing the problem with the chief pilot, it was concluded that the flight should return to Kalgoorlie about ten minutes before last light. The aircraft subsequently departed Kalgoorlie at 1221 hours, and the flight proceeded uneventfully. However, delays en-route and in refuelling resulted in the aircraft not departing Jameson until 1609 hours. Based on the flight plan time intervals, the expected arrival time at Kalgoorlie was 1844 hours which was an hour after last light. The pilot did not hold the necessary qualification allowing him to operate a multiengined aircraft at night, although he held such a rating for single-engined aircraft. He elected to proceed as planned, and declared the last section of the flight a Mercy Flight. At 1828 hours, when 55 km from Kalgoorlie, the pilot contacted Kalgoorlie Flight Service Unit and received details of the weather, as recorded thirty minutes earlier. This information included an observation of lightning to the west-south-west and a line of thunderstorms from north-west to south of the aerodrome. At 1840 hours, when about 13 km from Kalgoorlie he advised that he would use runway 28. No further communication was heard from the aircraft. Witnesses at Boulder, 4 km east of Kalgoorlie, subsequently reported that a severe squall entered the area shortly before the aircraft was seen turning on to final approach for the runway. The strong wind had generated dust clouds and the aircraft was seen to enter one of these, whilst executing a number of sudden attitude changes. It then collided with a mineshaft headframe. The left wing was torn from the aircraft which then crashed to the ground nearby. A passenger was seriously injured while four other occupants were killed.
Probable cause:
There is insufficient evidence available to enable the cause of this accident to be determined. It is evident however, that the aircraft encountered severe turbulence at a low height during the approach for landing. No pre-existing defect or malfunction which could have contributed to the accident was found during the examination of the wreckage.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601P) in Teutonic Bore: 1 killed

Date & Time: May 28, 1980 at 1137 LT
Operator:
Registration:
VH-KXY
Flight Phase:
Survivors:
Yes
Schedule:
Teutonic Bore – Leonora – Perth
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2810
Captain / Total hours on type:
149.00
Circumstances:
The aircraft was engaged on the return segment of a flight from Perth to Teutonic Bore, with an intended refuelling stop at Leonora. After embarking the two passengers and their baggage, the pilot started the engines and taxied for a take-off into the north, on the 1350 metre long main strip. The weather conditions were fine with a northerly surface wind of about 7 knots. The initial part of the take-off run was apparently normal but, after travelling some 400 metres and at about the point of rotation, one of the passengers noted an engine power surge. The take-off was continued, the aircraft became airborne and shortly afterwards the landing gear was retracted. After the aircraft had slowly climbed straight ahead to an altitude of about 200-300 feet above ground level, the passenger heard a marked change in the engine noise and felt the aircraft decelerating. The extent of the power loss and the absence of any yawing force indicated both engines had lost power simultaneously. Level flight straight ahead was reportedly maintained for an estimated 10 seconds and then the aircraft entered a descending left turn. At about this time the pilot, in response to a query from the passenger, advised that he intended to return to the airstrip but then stated "we're going down", or words to that effect. The terrain in the area was generally firm and flat. It was lightly covered with scrub and there was occasional small trees but a safe landing with only minimal damage was possible. When VH-KXY struck the ground the gear and flaps were retracted and the rate of descent was high. The aircraft was in a level attitude but yawed approximately 45 degrees to the right. After the initial impact, the aircraft slid across the ground on a track of 220 degrees magnetic for 67 metres before coming to rest. There was no post-impact fire. One passenger was able to exit via the cabin door by his own efforts. The other occupants were trapped in the wreckage and were rescued some 30 minutes later by persons who attended the accident. The pilot died shortly after being removed from the aircraft.
Probable cause:
The probable cause of the accident was that, following a substantial loss of power by both engines, the pilot did not carry out the procedures necessary for a safe forced landing. The cause of the loss of power by both engines has not been determined.
Final Report: