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Crash of a Piper PA-31-350 Navajo Chieftain in Launceston: 6 killed

Date & Time: Sep 17, 1993 at 1943 LT
Operator:
Registration:
VH-WGI
Survivors:
Yes
Schedule:
Melbourne - Launceston
MSN:
31-7305075
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
701
Captain / Total hours on type:
3.00
Aircraft flight hours:
8712
Circumstances:
Members of a football club had planned to visit Launceston, travelling by light aircraft. Three aircraft were needed to carry the group, with all passengers and pilots contributing to the cost of the aircraft hire. One of the club members, who was a pilot, organised the required aircraft and additional pilots for departure from Moorabbin Airport on the afternoon of 17 September 1993. The operator from whom the aircraft were hired, who also employed the organising pilot as an instructor, arranged for one Piper PA-23 (VH-PAC), a Piper PA-31-310 (VH-NOS) and a Piper PA-31-350 (VH-WGI) to be available for the trip, with the organising pilot to fly VH-WGI. On the day of the flight the pilot of VH-WGI carried out pre-flight inspections, obtained the weather forecasts and submitted flight plans for all three aircraft. The flight plans for the two PA-31 aircraft were for flights operated in accordance with IFR procedures. The PA-23 was to operate in accordance with VFR procedures. The TAF for Launceston predicted 2 octas of stratocumulus cloud, base 2,000 ft and 3 octas of stratocumulus cloud, base 3,500 ft. The flight plan for VH-WGI (see fig. 2) indicated that the aircraft would track Moorabbin Wonthaggi-Bass-Launceston and cruise at an altitude of 9,000 ft. A cruise TAS of 160 kts, total plan flight time of 90 minutes, endurance 155 minutes and Type of Operation 'G' (private category flight) were specified. No alternate aerodrome was nominated and none was required. The estimated time of departure was 1730. The flight plan was submitted to the CAA by facsimile at 1529. Last light at Launceston was 1919. VH-WGI departed Moorabbin at 1817 and climbed to an en-route cruise altitude of 9,000 ft. The pilot was required to report at Wonthaggi but passed this position at 1832 without reporting. Melbourne ATC tried unsuccessfully to contact the pilot because of this missed report. Later, the Melbourne radar controller noticed the aircraft deviating left of track but was unable to make contact. Communications were re-established at 1858 when the pilot called Melbourne FS saying he had experienced a radio problem. By this time the aircraft heading had been corrected to regain track. At 1927 the pilot called Launceston Tower and was cleared for a DME arrival along the inbound track of the Launceston VOR 325 radial. The Launceston ATIS indicated 2 octas of cloud at 800 ft, QNH 1,012 hPa, wind 320° at 5-10 kts, temperature +10° and runway 32 in use. At 1930 the ADC advised the pilot that the 2 octas of cloud were clear of the inbound track, but that there was some lower cloud forming just north of the field, possibly on track. He informed the pilot that there was a chance he might not be visual by the VOR, in which case he would need to perform an ILS approach via the Nile locator beacon. The ADC contacted the airport meteorological observer at 1933, inquiring as to what the 1930 searchlight check of cloud height had revealed. He was told the observation indicated 7 octas of cloud at about 800 ft. At 1935.52 (time in hours, minutes and seconds) the ADC asked the pilot for his DME (distance) and level. The pilot responded that he was at 12 DME and 3,300 ft. The ADC told the pilot that conditions were deteriorating with probably 4 octas at 800 ft at the field. He then told the pilot he would hopefully get a break in the cloud, but then restated that if he was not visual by the VOR to make a missed approach, track to Nile and climb to 3,000 ft. At 1939.45 the pilot was again asked for his DME and level. He indicated that he was at 1,450 ft and 2-3 DME. He then also confirmed that he was still in IMC. There were three other aircraft inbound for Launceston and the ADC made an all-stations broadcast that conditions were deteriorating at Launceston, with 4 octas at 800 ft, and to expect an ILS approach. At 1940.56 the pilot stated that he was overhead the field, but did not have it sighted and was going around. At 1941.07 the pilot reported that he had the airfield in sight and at 1941.16 that he was positioned above the final approach for runway 32. Fifteen seconds later the pilot reported that he was opposite the tower and was advised by the ADC that he was cleared for a visual approach, or a missed approach to Nile as preferred. The pilot indicated he would take the visual approach and was then told to manoeuvre as preferred for runway 32. This was acknowledged at 1941.48. No further communications were received from the pilot. The ADC made a broadcast to two other inbound aircraft at 1942.32, advising that VH-WGI was in the circuit ahead of them, that it had become visual about half a mile south of the VOR, that it was manoeuvring for a visual approach and was just in and out of the base of the cloud. After the pilot of VH-WGI reported over the field, and the aircraft first appeared out of cloud, witnesses observed it track to about the south-east end of the aerodrome at a height of about 500-800 ft. It then turned left to track north-west on the north-east side of the main runway and approximately over the grass runway. The aircraft was seen to be travelling at high speed, and passing through small areas of cloud. North of the main terminal building a left turn was initiated onto a close downwind leg for runway 32. The aircraft appeared to descend while on this leg. As the base turn was started, at a height estimated as 300-500 ft, the aircraft briefly went through cloud. Some of the witnesses reported that the engine noise from the aircraft during the approach was fairly loud, suggestive of a high power setting. Late on a left base leg the aircraft was observed to be in a steep left bank, probably in the order of 60°, at a height of about 200 ft. It then descended rapidly and struck a powerline with the right wing, approximately 28 ft AGL, resulting in an airport electrical power failure at 1943.02. Almost simultaneously the left wing struck bushes. A short distance beyond the powerlines the aircraft struck the ground and slid to a stop. A fierce fire broke out immediately. Airport fire services responded to the accident and the fire was quickly extinguished. Six of the occupants received fatal injuries and the others, including the pilot, were seriously injured.
Probable cause:
The following findings were reported:
1. The actual weather at Launceston at the time of arrival of VH-WGI was significantly worse than forecast.
2. The pilot did not have the required recent experience to conduct either an IFR flight or an ILS approach. The operator's procedures did not detect this deficiency.
3. The pilot's inexperience and limited endorsement training did not adequately prepare him for IFR flight in the conditions encountered.
4. The CAA did not specify adequate endorsement training or minimum endorsement time requirements for aircraft of the class of the PA-31-350, particularly in regard to the endorsement of inexperienced pilots.
5. An absence of significant decision-making training requirements contributed to the poor decision-making action by the pilot who decided to continue with a visual circling approach at Launceston in conditions that were unsuitable for such an approach.
6. As a consequence of continuing the approach, the pilot subjected himself to an overwhelming workload. This was due to a combination of adverse weather conditions, his lack of training and experience in IFR approach procedures on the type, and a misinterpretation of (or non-compliance with) the AIP/DAP-IAL instructions, a combination which appears to have influenced the pilot to fly a close-in, descending circuit at low altitude. The carriage of alcohol-affected passengers may have also added to the level of difficulty.
7. Because of workload, and possibly also due to distractions, the pilot inadvertently allowed the aircraft to enter a rapid descent at a critical stage of the approach, at an altitude from which recovery could not be effected.
Final Report:

Crash of a De Havilland DH.114 Heron 2D in Launceston

Date & Time: Aug 4, 1983
Type of aircraft:
Operator:
Registration:
VH-CLY
Survivors:
Yes
Schedule:
Hobart - Launceston
MSN:
14122
YOM:
1957
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Launceston Airport, the aircraft was misaligned and the crew decided to initiate a go-around procedure. Gear were retracted and flaps were partially raised when the airplane lost height and struck fences. It crash landed and came to rest on the runway. All seven occupants escaped with minor injuries and the aircraft was damaged beyond repair.

Crash of a Bristol 170 Freighter 21E off Cape Paterson: 2 killed

Date & Time: May 10, 1975 at 0218 LT
Type of aircraft:
Operator:
Registration:
VH-SJQ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Melbourne - Launceston
MSN:
12807
YOM:
1946
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
18821
Captain / Total hours on type:
264.00
Aircraft flight hours:
9526
Circumstances:
The flight departed from Essendon Airport at 0050LT. At 0122 hours the flight reported to the Melbourne Flight Service Unit (FSU) that it was then at the Westgate reporting point cruising at 3,500 feet, and its estimated time of arrival at the West Bass reporting point was 0159 hours. At 0145:44 hours VH-SJQ advised the Melbourne FSU 'we have an engine failure on the port side, we have it feathered and are returning to Melbourne'. In response to a request from the FSU the flight advised it was able to maintain height 'at the moment'. At 0148:54 VH-SJQ confirmed that 'the port engine has failed and is feathered' and shortly thereafter advised an estimated time of arrival at the Primegate reporting point en route to Essendon Airport. The Uncertainty Phase of the search and rescue procedures was declared by the Melbourne Air Traffic Control Unit (ATC). At 0151:58 hours the flight advised the Melbourne FSU 'we are making a slow descent to one five zero zero' and, in answer to a query, reported 'we're unable to maintain our height with our rated power'. The Alert Phase of the search and rescue procedures was declared by Melbourne ATC, and a Bristol 170 Mark 31 aircraft en route from Launceston to Essendon Airport was diverted to intercept VH-SJQ and act as an escort. At 0157:46 hours VH-SJQ reported 'four eight DME Wonthaggi', and shortly thereafter, reported 'tracking one eight three on the Wonthaggi VOR'. At 0203:00 hours VH-SJQ transmitted a distress call and reported 'we're passed fifteen hundred feet and still going down'. The position of the aircraft at 0203:57 hours was reported as 'on the one eight six radial Wonthaggi and we are three seven DME'. The Distress phase of the search and rescue procedures was declared by Melbourne ATC and a second northbound aircraft was diverted to intercept VH-SJQ. At 0204:32 hours VH-SJQ reported 'we're down to nine hundred feet at the moment'; at 0207:42 hours, 'at six hundred feet at the moment; at 0212:55 hours, 'two two DME'; at 0213:22 hours, altitude was 200 feet; 0214:31 hours, 'we're down to one hundred feet'; and, at 0215:23 hours, 'this is a final MAYDAY call, we are approximately one eight DME and our altimeters registering zero feet'. Melbourne FSU then transmitted a ditching report of moderate seas with a moderate south-westerly swell; this was acknowledged by VH-SJQ. The escort aircraft then heard further transmissions from VH-SJQ which indicated that both altimeters were reading zero; the crew could see the tops of waves; and DME distances of 16, 15 and 14 were transmitted, the latter being the last transmission heard from the aircraft the time being about 0218 hours. Neither of the escort aircraft sighted VH-SJQ. Post analysis of the meteorological information indicates that the weather in the area of the accident was: surface wind from 280 degrees (True) at 15 knots, scattered cumulus cloud base 2,500 feet, scattered stratus cloud base 1,200 feet, patches of sea fog, visibility 40 kilometres reducing to 4,000 metres in rain showers, temperature 12° Celsius. It is probable that the temperatures at 1,500 feet, 2,500 feet, and 3,500 feet were 9.5°, 7° and 5° Celsius respectively. The conditions were not conducive to the formation of airframe or carburettor icing, and search aircraft in the area did not encounter any such icing.
Probable cause:
Due to lack of evidences, it was not possible to determine the exact cause of the accident. Analysis of the information available indicates that the flight profile flown by VH-SJQ is compatible with the aircraft having been flown at an indicated airspeed of 95 knots, and a power output from the starboard engine of 1250 BHP, i.e. 26 per cent less than the normal maximum power available in the conditions which prevailed. The pilot did not indicate in detail the nature of the difficulties he was experiencing, and as the majority of the aircraft wreckage has not been found it has not been possible to determine why he shut down the port engine; whether or not there was a degradation in the power output of the starboard engine; or whether there was some other factor which might have affected the performance of the aircraft. It might be significant, however, that at 0208:33 hours when a crew inter-communication was inadvertently transmitted from VH-SJQ, it was stated 'cylinder head is about three forty, oil pressure is around about eighty, oil temperature is about ah sixty five'. Such an oil pressure and temperature is normal, but the reported cylinder head temperature is 30 degrees Celsius in excess of the permissible emergency maximum.
Final Report:

Crash of a Fokker F27 Friendship 200 in Launceston

Date & Time: Mar 17, 1965
Type of aircraft:
Operator:
Registration:
VH-FNH
Survivors:
Yes
Schedule:
Melbourne – Launceston – Hobart
MSN:
10180
YOM:
1961
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
7500
Aircraft flight cycles:
8011
Circumstances:
To avoid turbulence over the mountain area near Launceston, the cruising level was maintained prior to entry into the airport circuit pattern. Just prior to turning for finals, trouble was experienced in the pitch-lock mechanism of the no. 1 prop. The prop was feathered and the approach was continued with full flaps, but without immediately increasing power on the remaining engine. The high rate of descent was not arrested during the turn, resulting in a slightly low altitude. Power was added and speed reduced to control the descent rate, but the crew were unable to maintain runway heading. An overshoot was attempted, but the speed had dropped below minimum control speed. The left wing dropped as full power was applied to the no. 2 engine. The wing struck the ground and the aircraft crashed, coming to rest 740 feet abeam the runway threshold. Fuel tanks ruptured and caused a fire, which was quickly extinguished. All 23 occupants escaped uninjured while the aircraft was destroyed.

Crash of a Douglas DC-3-232 in Mangalore

Date & Time: Dec 29, 1948
Type of aircraft:
Operator:
Registration:
VH-UZJ
Flight Type:
Survivors:
Yes
Schedule:
Launceston - Melbourne
MSN:
2002
YOM:
1937
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew (two pilots and one stewardess) was positioning from Launceston to Melbourne. On approach to Essendon, poor weather conditions forced ATC to close the airport to all trafic and VH-UZJ was diverted to Mangalore Airport. On approach, the aircraft was too low, crashed in a field and broke in two. All three crew members were injured and the aircraft was written off.
Probable cause:
Poor judgement on part of the pilot who continued the approach at an unsafe altitude.

Crash of a De Havilland DH.86 in Bass Strait: 5 killed

Date & Time: Oct 2, 1935 at 0955 LT
Type of aircraft:
Operator:
Registration:
VH-URT
Flight Phase:
Survivors:
No
Schedule:
Sydney – Melbourne – Launceston – Hobart
MSN:
2312
YOM:
1935
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
While cruising over Bass Strait, between Tasmania and Australia, the four engine aircraft christened 'Loina' went out of control and crashed into the sea, some 3 km off Flinders Island. All five occupants were killed.
Crew:
Arthur Evans, pilot,
Maxwell Brown, copilot.
Passengers:
G. S. Anderson,
G. Garlick,
Edward Best.
Probable cause:
It was determined that VH-URT had gone into an uncontrollable spin, and three possible precipitating factors were: a loss of control after a power plant failure, the fouling of the tail surfaces while the trailing aerial was being reeled in or a structural failure. There was also evidence of a small fire in the rear of its cabin, which may have occurred before the crash, but this probably did not factor in the accident. And in view of two fatal accidents and other difficulties with the type, Australia would subsequently suspend the certificate of airworthiness of the De Havilland 86.

Crash of a De Havilland DH.86 in Bass Strait: 11 killed

Date & Time: Oct 19, 1934
Type of aircraft:
Operator:
Registration:
VH-URN
Flight Phase:
Survivors:
No
Schedule:
Launceston – Melbourne
MSN:
2301
YOM:
1934
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
While overflying Bass Strait, the four engine aircraft christened 'Miss Hobart' crashed in unknown circumstances some 10 miles off the coast of the Wilsons Promontory National Park. SAR teams found some debris and oil leak at the surface of water a day later but no trace of the occupants was ever found. Captain V. Holyman, who was among the missing, was the pilot and co-founder of the airliner.
Probable cause:
The cause of the crash could not be determined. However, one of the recommendations made by the accident investigative commission was to prohibit the changing of pilots in an aircraft while in flight, since one theory into the disappearance of VH-URN pointed to a loss of control resulting from such action by the crew.