Piper PA-31 Cheyenne

The pilot's failure to maintain airplane control following an emergency, the nature of which could not be determined because of crash and fire damage, which resulted in an aerodynamic stall.

The pilot’s failure to regain airplane control following a sudden rapid descent during cruise flight, which resulted in an exceedance of the design stress limits of the aircraft and led to an in-flight structural failure.

The following findings were identified:
- Fatigue is likely to have occurred, since there are reports of high workload, capable of affecting the perception, judgment, and decision making of the crew.
- In view of the fact that the captain displayed an attitude of gratefulness toward the company which hired him, working for consecutive hours and many times more than was prescribed for his daily routine, it is possible that such high motivation may have been present in the accident flight, harming his capacity to evaluate the conditions required for a safe flight.
- The crew neither gathered nor properly evaluated the available pieces of information for the correct refueling of the aircraft, something that led to their decision of not refueling the aircraft in SBDO.
- The company crews did not usually keep fuel records, and made approximate calculations based on the fuel remaining from previous flights, whose control parameters were not dependable. Such attitudes reflected a work-group culture that became apparent in this accident.
- The pilots were presumably undergoing a condition of stress on account of the company flight routine, in which they flew every day, with little time dedicated to rest or even holidays. Under such condition, the pilots may have had their cognitive processes affected, weakening their performance in flight.
- The flights had the objective of transporting valuables, causing concern in relation to security issues involving the aircraft on the ground. Thus, it is suspected that decisions made by the pilots may have been affected by this complexity, such as, for example, deciding not to refuel the aircraft on certain locations.
- The way the work was structured in the company was giving rise to overload due to the routine of many flights and few periods of rest or holidays. This situation may have affected the crew’s performance, interfering in the analysis of the conditions necessary for a safe flight.
- The company did not monitor the performance of its pilots for the identification of contingent deviations from standard procedures, such as non-compliance with the MGO.
- Failures in the application of operational norms, as well as in the communication between the crew members, may have occurred on account of inadequate management of tasks by each individual, such as, for example, the use of the checklist and the filling out of control forms relative to fuel consumption contained in the company MGO.
- The crew judged that the amount of fuel existing in the aircraft was sufficient for the flight in question.
- The fact that the fuel gauges were not indicating the correct quantity of fuel had direct influence on the flight outcome, since the planning factors and the pilots’ situational awareness were affected.
- The crew did not analyze appropriately the amount of fuel necessary for the flight leg between SBDO and SBBI. The Mission Order did not establish the minimum amount of fuel necessary for the flight legs, and the crew had to take responsibility for the decision.
- The company was not rigorous with the filling out of aircraft logbooks and cargo manifestos, resulting that it did not have control over the operational procedures performed by the crews, and this may have contributed to the aircraft taking off with an amount of fuel that was insufficient for the flight. Although the MGO had parameters established for calculating the endurance necessary for VFR/IFR flights, the company did not define the fuel necessary in the Mission Orders, transferring the responsibility for the decision to the aircraft captain.

Belly landing on runway 19 after the pilot forgot to lower the landing gear while approaching the airport.
The following contributing factors were identified:
- Probable distraction of the pilot by keeping his attention mainly on the GPS equipment to maintain the flight path and avoid unnecessary engine power adjustments,
- The pilot failed to follow the approach and landing checklist,
- The pilot failed to check the three gear lights on the cockpit panel,
- The pilot performed an unstabilized approach without completing the pre-landing checklist and eventually stabilized the airplane at a height of 500 feet.

Causes of the Accident:
It is likely that during the final approach, a right engine anomaly, detected by the pilot, led to power asymmetry. As a result of a high workload, during the phase of deceleration and gear and flap extension, the pilot likely did not monitor the indicated airspeed, or noted a decrease in it. He may then have encountered difficulties in managing the power asymmetry before losing control of the aeroplane.
The following factors may have contributed to the accident:
- continuation of a fast arrival in a cloud layer, at night to a height of about 1,000 feet before configuring the aeroplane to land, which resulted in a significant increase in the pilot’s workload during processing of the anomaly;
- probable fascination with the objective given the proximity of the runway and the attraction induced by the approach lights;
- degraded type rating training to adapt to the pilot’s constraints during its renewal;
- absence of specific exercises relating to the conduct of a single engine approach at a speed close to VMCA, in the type rating training for single pilot multi-engine high performance aeroplanes.

The most likely cause of the accident would have been the loss of control of the aircraft when performing the flare, caused by a loss of lift (stall), because the CofG was beyond the rear limit.
The following contributing factors were identified:
- The aircraft was unstable on its longitudinal axis because the CofG was too far aft,
- The cargo was not properly secured in the cabin.

Contributing safety factors:
• While the aircraft was climbing to 9,000 feet the right engine sustained a power problem and the pilot subsequently shut down that engine.
• Following the shutdown of the right engine, the aircraft's descent profile was not optimized for one engine inoperative flight.
• The pilot conducted a descent towards Bankstown Airport that was consistent with a normal arrival profile without first verifying that the aircraft was capable of achieving adequate performance with one engine inoperative.
• Following the engine problem, the aircraft's flightpath and the pilot’s communication with air traffic control indicated that the pilot's situation awareness was less than optimal.
• The aircraft collided with a powerline support pole on the eastern side of the intersection of Sackville Street and Canley Vale Road, Canley Vale, about 6 km north-west of Bankstown Airport.
Other safety factors:
• The pilot did not broadcast a PAN following the engine shutdown and did not provide air traffic control with further information about the nature of the problem in order for the controller to positively establish the severity of the situation.
• Section 4 of Civil Aviation Advisory Publication (CAAP) 5.23-2(0), Multi-engine Aeroplane Operations and Training of July 2007 did not contain sufficient guidance material to support the flight standard in Appendix A subsection 1.2 of the CAAP relating to Engine Failure in the Cruise. [Minor safety issue]
Other key finding:
• Given the pilot’s extensive experience and testing in the PA-31 aircraft type, and subsequent endorsement training on a high performance turboprop multi-engine aircraft since the issue by CASA in 2008 of a safety alert in respect of the pilot’s PA-31 endorsement, it was unlikely that any deficiencies in that endorsement training contributed to the accident.

The pilot's failure to maintain airplane control during final approach.