Crash of a Beechcraft Super King Air B200 in Melbourne: 5 killed

Date & Time: Feb 21, 2017 at 0859 LT
Registration:
VH-ZCR
Flight Phase:
Survivors:
No
Site:
Schedule:
Melbourne - King Island
MSN:
BB-1544
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
Shortly after takeoff from Melbourne-Essendon Airport runway 17, while in initial climb, the pilot encountered technical problems and declared an emergency. The twin engine aircraft then banked left and crashed in flames onto a shopping mall located near the airport. The aircraft was destroyed upon impact and all five occupants have been killed. Apparently, an engine failed during initial climb, forcing the crew to return.

Crash of a De Havilland DH.104 Dove 5 in Melbourne

Date & Time: Dec 3, 1993 at 2037 LT
Type of aircraft:
Operator:
Registration:
VH-DHD
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Melbourne - Melbourne
MSN:
04104
YOM:
1948
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18154
Captain / Total hours on type:
1500.00
Aircraft flight hours:
21259
Circumstances:
The pilot had planned to conduct a night charter flight over Melbourne and Port Phillip Bay, starting from and returning to Essendon Airport. Dinner was to be served in flight. The pilot gave a safety briefing to the passengers before starting the engines. He completed engine runups and pre-takeoff checks, including selecting 20° of flap. At 2036 ESuT, in daylight, the pilot initiated takeoff on runway 17 using standard take-off power setting of 7.5 lb/in2 of boost and 3,000 RPM. Wind conditions were light and variable, visibility was about 10 km and the temperature was 19°C. The aircraft became airborne and, just as it achieved the take-off safety speed of 84 kts, at a height not above 50 ft, the right engine lost power. The aircraft yawed right. The pilot reported to the investigation team that he briefly noticed a reading of 3 lb of boost on the MAP gauge and assessed the problem as a possible partial right engine failure. He then selected the landing gear up but it did not retract. He cycled the landing gear selector once and the gear then retracted. By this time several seconds had elapsed and the airspeed had decayed to 76 kts. The pilot then assessed the airspeed as too low to retract the flaps and left them at 20°. The airspeed continued to decay until VMCA, 72 kts, was reached. When indicated airspeed had further decayed to 68 kts, the pilot reduced power on the left engine to avoid an uncontrollable roll to the right. He was able to maintain wings level and attempted to track the aircraft toward a street but was unable to maintain height. The aircraft collided with powerlines and then struck the roofs of several houses before coming to rest, on its left side, against the front wall of a house. About one minute had elapsed from initiation of takeoff until the accident. The pilot and all but one of the passengers remained conscious throughout the accident sequence. All occupants were evacuated, some without assistance and others with the assistance of the pilot, other passengers, emergency services personnel or bystanders.
Probable cause:
The following factors were reported:
- The right engine fuel control unit fuel pump failed causing the engine to fail at a critical phase of flight.
- Maintenance inspections did not detect the abnormal wear on the thrust face of the right engine fuel control unit fuel pump.
- The landing gear did not retract on the first attempt and aircraft performance decayed while the pilot resolved this problem.
- The pilot was probably forced to abandon the emergency procedures to concentrate on maintaining control of the aircraft.
- The aircraft was unable to maintain altitude and airspeed with the right propeller windmilling and 20° of flap.
- The investigation identified organisational factors concerning deficiencies in the manuals and procedures available to, and used by, the operator for the operation and maintenance of the accident aircraft.
Final Report:

Crash of a Cessna 414A Chancellor near Wonthaggi

Date & Time: Oct 27, 1989 at 0833 LT
Type of aircraft:
Operator:
Registration:
VH-SDV
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Melbourne – Port Welshpool
MSN:
414A-0261
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot reported that whilst enroute from Essendon to Wonthaggi he descended to the lowest safe altitude of 3600 feet above sea level, lowered the landing gear, reduced power and airspeed to counter the effect of turbulence and entered a holding pattern to the south south west of the Wonthaggi navigation aid. During the holding pattern the aircraft descended until it collided with trees that were 865 feet above sea level. The weather at the time included gale force winds, rain and low cloud. There were no thunderstorms or microbursts in the area, however, other aircraft reported a very low cloud base and severe turbulence. A few minutes prior to the accident ground witnesses, south south west of the accident site, reported an aircraft matching the description of VH-SDV, flying below a low, misty, ragged cloud base. There was no record of another aircraft in the area at the time. Information was available which indicated that the aircraft had descended below 3600 feet during the approach to Wonthaggi. The passengers reported that the pilot gave no indication of any problem or danger. Until the impact, they believed the aircraft was descending normally for a landing at Port Welshpool.
Probable cause:
No aircraft defects were found which may have been factors in the accident. The investigation indicates that the pilot attempted to fly under the low cloud base, in order to reach the Port Welshpool destination where weather conditions were earlier reported to have been partially sunny. Port Welshpool is not serviced by an approved navigation aid. The pilot attempted to descend below the cloud base, hoping to achieve visual flight conditions to continue to his destination.
Final Report:

Crash of a Cessna 402A in Melbourne: 6 killed

Date & Time: Sep 3, 1986
Type of aircraft:
Registration:
VH-RED
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Melbourne - Leongatha
MSN:
402A-0130
YOM:
1969
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The flight was intended to return patients to their home area following medical treatment in Melbourne. After an apparently normal take-off, the aircraft ceased climbing at about 100 feet above ground level. In response to a query from the Tower, the pilot advised that the left engine had failed, that he was feathering the propeller and would return for landing. The aircraft was seen to be deviating to the left, towards a large array of power lines. These lines extend from about 40 feet to 90 feet above the ground, and as the aircraft converged with the array it was probably below the height of the upper wires. The aircraft then suddenly veered to the left and subsequently struck the ground in a steep nose-down attitude. A fire broke out on impact and destroyed much of the wreckage. The final manoeuvre performed by the aircraft was typical of that which occurs when one engine of a twin-engine aircraft is producing considerably less power than the other, and airspeed is reduced to below that required to maintain directional control. The pilot had reported that the left engine had failed, and the loss of control as described by witnesses was consistent with a reduction of power from this engine, combined with low airspeed.
Probable cause:
The investigation of the accident was hampered by the extent of the fire damage. However, an extensive technical examination did not reveal any evidence of a defect or malfunction with either the engines, the various systems or the airframe which might have contributed to the accident. Although the pilot had indicated that he was feathering the left propeller, it was determined that the propeller was not feathered at the time of the accident. It was not possible to establish if the pilot had subsequently elected not to initiate feathering action, or whether such action was initiated too late for it to be completed before impact with the ground. The reason for the loss of performance reported by the pilot could not be established. It is likely that while the aircraft was being manoeuvred to avoid the power lines and return for a landing, the airspeed decayed to below the minimum required to enable adequate control of the aircraft to be maintained. At the point where control of the aircraft was lost, there was insufficient height available for the pilot to effect recovery. The reason continued flight was attempted, rather than a controlled forced landing in open areas prior to the power lines, could not be determined.
Final Report:

Crash of a Mitsubishi MU-2B-60 Marquise in Bargo: 1 killed

Date & Time: May 24, 1983 at 0433 LT
Type of aircraft:
Operator:
Registration:
VH-MLU
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sydney - Melbourne
MSN:
1527
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft was cleared via a Standard Instrument DEPARTURE with an unrestricted climb to Flight Level (FL) 220. The aircraft climbed on track at an average rate of 1300 ft/min until FL130. The rate of climb then reduced to 350 ft/min until FL140, when the rate of climb increased to 1800 ft/min. At FL160 the aircraft entered a near vertical descent and radar contact was lost one minute later at 3100 feet. The aircraft impacted the ground in a near vertical attitude. The pilot, sole on board, was killed.
Probable cause:
Despite an extensive investigation, the reason for the loss of control leading to this accident could not be determined. There have been several other reported occurrences involving sudden loss of control in this aircraft type and the United States Federal Aviation Administration has conducted a certification review of the type. The results of that review do not appear to indicate any factors relevant to this particular accident.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Portland: 1 killed

Date & Time: Jan 26, 1981 at 1538 LT
Registration:
VH-POC
Flight Phase:
Survivors:
Yes
Schedule:
Portland - Melbourne
MSN:
31-7952087
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
815
Captain / Total hours on type:
83.00
Circumstances:
The operator had undertaken to carry out a ship's crew exchange programme that consisted of transporting 16 persons and their baggage from Portland to Essendon and the same number back to Portland. Similar programmes had been carried out previously and it was known that the passengers usually carried considerable baggage. However, only two Piper PA-31-350 aircraft, VH-POC and VH-RNH, were assigned to the task. Prior to departure Essendon, both pilots attended the Briefing Office and prepared flight plans, intended to operate under the Instrument Flight Rules and the pilots calculated it would be necessary to load 208 minutes fuel for the first return flight to Portland. This included an additional 30 minutes fuel for holding, as was required because of forecast thunderstorm activity, with associated reduced visibility in rain, in the Essendon area. Both pilots elected to have their aircraft refuelled to capacity which, they indicated on their flight plans, would give them a total of 280 minutes endurance; 72 minutes more than required. The aircraft proceeded to Portland without known incident, arriving at about 14:00 hours. After a break for refreshments, the pilots returned to their aircraft at about 1500 hours and carried out pre-flight checks. The passengers arrived at the aerodrome in a number of vehicles. Initially the pilots began to weigh the baggage and record the weights on a manifest. The passengers were in a light-hearted mood, however, and with an atmosphere of some confusion, not all of the baggage was weighed, the manifest was not completed and no individual weights were marked on the bags.The baggage was then transported by trolleys to the aircraft and shared between them without consideration of weight. The baggage in the rear baggage area of the cabin of VH-POC was not restrained to prevent movement. The pilots decided that, by inspection, the average baggage weight per passenger was 20 kg. The accepted standard weight of 77 kg per adult passenger was also assumed. Each pilot then completed a load sheet for his aircraft, on the basis of carrying eight passengers. The sheet for VH-POC indicated that the aircraft fuel load was 290 kg. The total weight calculated for VH-POC was 3,080 kg. This was less than the maximum allowable all-up-weight of 3,178 kg. However, an incorrect aircraft operating weight had been used and an arithmetical error had occurred in the calculation. Correcting for these, the aircraft weight should have been recorded as 3,256 kg. When ready to embark, the passengers were only directed towards the two aircraft. No effort was made to split the party into two even groups and in the event, nine passengers boarded VH-POC. On boarding VH-POC, the pilot did not correct the passenger imbalance. He started both engines and proceeded to taxi for a take-off on Runway 22. Pre-take-off checks were carried out as the aircraft taxied. The weather conditions at the time were fine; visibility 15 km, temperature 22° Celsius, sea level barometric pressure 1007 millibars and surface wind from 210° to 220° magnetic, gusting from 25 to 35 knots. In such wind conditions, and because of the location near a coastal headland, there was significant turbulence present. The pilot of VH-POC had operated into Portland on numerous prior occasions and had experienced this common situation previously. The take-off run was commenced and the pilot reported that full power was obtained from both engines. He stated that at 95 kts the aircraft was rotated and, when a positive rate of climb had been established, the landing gear was retracted. Then, at a height of 60 to 70 feet, just after he had reduced power to the climb setting, the left engine suddenly lost power. Ground witnesses who observed the take-off reported that the aircraft appeared slow to accelerate. Once airborne, it maintained a low climb profile and, at one stage, slewed to the right. Irregular engine noise was heard but it was not identified to a particular engine. The pilot reported that he confirmed a left engine failure by closing the left throttle. On fully re-opening the throttle, however, he noted a slight power response and hence he elected not to shut down the engine and feather the left propeller. Several of the passengers were aware of an abnormal situation but none was aware of the nature of the problem nor could confirm which engine was malfunctioning. They reported that the landing gear audio warning was sounding throughout most of the flight, which indicated a throttle was at or near the closed position. The pilot reported that the aircraft began to lose height and, as a forced landing was imminent, he turned to the right to avoid the sea. Control had been difficult in the gusty conditions but he had managed to reduce speed, lower the landing gear and guide the aircraft to a landing in a reasonably suitable area. The aircraft touched down on undulating-, sandy scrub-covered terrain. The landing gear and engines were torn out and the aircraft came to rest after travelling only some 26 metres. The fuselage broke open near the rear door during the ground slide. Some passengers were able to evacuate the cabin without assistance and they rendered help to the pilot and other passengers. A small fire, which had ignited in the vicinity of the left engine as the aircraft came to rest, then suddenly spread and engulfed the fuselage before the final passenger could be extricated. Subsequent examination of the wreckage was hampered by the extensive fire damage. No pre-existing fault was found in those components that were recovered. An inspection of the left propeller found that it had been feathered at ground impact. It was not possible to establish precisely the aircraft's weight and centre of gravity at the time of the accident as the contents of the nose and engine nacelles baggage compartments were destroyed. The available evidence, however, indicated that the aircraft weighed at least 3400 kg and its centre of gravity was probably beyond the aft limit. Piper PA31-350 performance data indicated that, for a new aircraft, the maximum attainable single-engine rate of climb at the limit weight of 3,178 kg was 220 feet per minute. At a weight of 3,400 kg this would be reduced by about 40 percent to 134 feet per minute. At the higher weight, detracting factors such as aircraft age, turbulence and less than optimum airspeed would have precluded the aircraft from achieving a positive rate of climb. The pilot was briefly interviewed in hospital on 27.1.81. At that time he also submitted a written notification of the accident. Subsequently, he has declined, through industrial counsel, to either attend for an interview under procedures of the Air Safety Investigation Branch or to supply answers to written questions. Hence it has not been possible to fully resolve a number of safety aspects of the accident, such as aircraft loading, the nature of the power loss and subsequent aircraft handling considerations.
Probable cause:
The probable cause of the accident was that the aircraft experienced a loss of power from one engine under conditions which precluded a safe continuation of flight. The two most significant conditions were aircraft overloading and turbulence. The nature and cause of the power loss have not been determined.
Final Report:

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

Date & Time: Aug 10, 1979 at 1508 LT
Operator:
Registration:
VH-ALH
Flight Type:
Survivors:
No
Schedule:
Whitemark - Melbourne
MSN:
500-1810-20
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8500
Captain / Total hours on type:
100.00
Circumstances:
During the morning of August 9, 1979, the aircraft was refuelled to capacity and three drums, each with a capacity of 20 litres, were also filled with fuel and placed in the baggage compartment. The aircraft, loaded with freight, subsequently departed Essendon at 1335 hours and proceeded to Cambridge where it arrived at 1536 hours. The freight was unloaded and, at 1621 hours, the aircraft departed for Launceston where it arrived at 1653 hours. It was again loaded with freight and departed Launceston at 1720 hours bound for Flinders Island. The aircraft landed at Flinders Island several minutes after the end of daylight, which was at 1745 hours, and the freight was unloaded. On the following day, the aircraft was again loaded with freight and the pilot subsequently reported departure from Flinders Island at 1329 hours, bound for Essendon. The take-off run was observed to be longer than usual for this type of aircraft and its rate of climb appeared to be less than normal. The IFR flight plan notified by the pilot before departure indicated his intention to cruise at an altitude of 4500 feet but, at 1410 hours, he reported to Melbourne Flight Service Unit "request traffic for a descent to proceed VFE we're getting 50 knot head wind here". On being advised that there was no traffic information, the pilot reported leaving 4500 feet. At 1502 hours, the pilot established communication with Essendon Tower, reported approaching Channel 0 at 1500 feet, and "request expedite clearance". He was issued with a clearance to enter controlled airspace at 1500 feet tracking from Channel 0 to Essendon via Clifton Hill. At 1506 hours he reported at Clifton Hill and, at 1507:38 hours, he advised "I'm sorry have a Mayday appear to have a fuel problem we'll have to land on a golf course". On being asked "which golf course?, the pilot replied "oh right where we are now". No further communications were received from the aircraft. The aircraft was observed by witnesses in the Northcote area initially on a north-westerly heading towards Essendon. E was seen to be descending and the sound of the engines was not normal. After flying over the northern section of the Northcote Municipal Golf Course, the aircraft commenced a descending left turn and [passed over a power transmission line which ran in a north-south direction near the western boundary of the golf course. As the turn continued towards an easterly heading, the aircraft again passed over the power line, at a very low height, and in strong tail wind conditions struck trees bordering a fairway while in a slightly left wing down, nose down, attitude. It struck the ground heavily just beyond the trees and the main wreckage travelled a further 73 metres before it came to rest on the edge of a green in the south-eastern corner of the golf course. Detailed examination of the wreckage of the aircraft revealed no evidence of any defect or malfunction which may have contributed to the accident. There was no significant fuel in the fuel systems of the two engines and there was negligible fuel in those cells of the fuel storage system which were undamaged. There was no fire. The pilot was in full time employment as an airline captain with a major operator. He was also involved financially and managerially in Norfish Pty. Ltd. and both he and the Company had financial difficulties at that time. The flight plan submitted by the pilot before departure from Essendon on August 9 contained false names in respect of both the pilot and the operator. Neither the pilot nor Norfish Pty Ltd held a Charter or Aerial Work Licence. The maximum specified take-off weight for the aircraft was 3357 kg. for VFR operations and 3243 kg. for IFR operations. It has been calculated that the gross weight of the aircraft was 3775 kg. when it departed Essendon for Cambridge on 9.8.79 and 3746 kg. when it departed Launceston for Flinders Island on the same day. The calculated gross weight was 4061 kg. when it departed Flinders Island on the day of the accident. Although fuel was available at Cambridge and Launceston, the aircraft was not refuelled after it 'departed from Essendon. The three 20 litre drums were located in the aircraft wreckage and, although all were damaged, detailed examination indicated that they ruptured under the action of hydraulic shock and that they wert filled at the time of the accident. The total operating time of the aircraft from departure Essendon until the time of the accident was consistent with a fuel endurance which could be expected in the circumstances leading to this accident.
Probable cause:
The cause of the accident was that the aircraft was operated with insufficient fuel to safely complete the flight.
Final Report:

Crash of a Partenavia P.68B in Melbourne: 6 killed

Date & Time: Jul 10, 1978 at 1853 LT
Type of aircraft:
Operator:
Registration:
VH-PNW
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Melbourne - Melbourne
MSN:
65
YOM:
1976
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
3512
Captain / Total hours on type:
2.00
Copilot / Total flying hours:
288
Copilot / Total hours on type:
34
Aircraft flight hours:
819
Circumstances:
The twin engine airplane was engaged in a local training flight at MelBourne-Essendon Airport, carrying one instructor, a pilot under supervision and a pilot's friend as passenger. Shortly after takeoff from runway 26, while climbing to a height of 200-250 feet, the pilot-under-supervision selected the wing flaps up and, at about this time, the pilot-in-command simulated an engine failure of one engine by closing a mixture control-believed to have been the starboard engine. The pilot-under-supervision identified the 'failed' engine, exercised the appropriate engine throttle to signify this identification and indicated the essential actions which would be taken in the event of an actual engine failure. The relevant controls were not operated. Following the completion of these actions full engine power was restored by the pilot-in-command. During the course of the simulated engine failure the aircraft assumed a nose down attitude. It then descended straight ahead with full engine power, passed through electric power cables outside the airport boundary at a height of 4.15 metres above terrain, and crashed into houses 286 metres beyond the western end of the runway. All three occupants were seriously injured while six people on the ground were killed, a seventh was injured as well.
Probable cause:
The cause of the accident was that the aircraft became grossly out of trim at a height which did not permit time for the crew to affect recovery. The manner in which the out-of-trim condition occurred has not been determined and the possibility of a trim system malfunction cannot be eliminated. However, the more likely explanation is that the command trim switch was activated unknowingly.
Final Report:

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 Rockwell Shrike Commander 500S in Warracknabeal

Date & Time: May 6, 1969 at 1935 LT
Registration:
VH-EXT
Survivors:
Yes
Schedule:
Melbourne – Warracknabeal
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5427
Captain / Total hours on type:
966.00
Circumstances:
At approximately 1935 hours EST on 6 May, 1969 an Aero Commander 500S aircraft, registered VH-EXT, struck the ground and crashed 2 miles west of Warracknabeal Aerodrome, Victoria, while making an approach to land at that aerodrome. The aircraft was owned and operated by Executive Air Services Pty. Ltd. of Melbourne and at the time of the accident it was engaged on a scheduled passenger commuter service between Essendon and Warracknabeal. The pilot, Allan James WALKER, and one passenger received minor injuries. A second passenger, the only other occupant, was seriously injured. The aircraft was virtually destroyed by impact forces. The pilot, aged 28 years, held a Current Commercial Pilot Licence, which was endorsed for the Aero Commander type of aircraft. He was the holder of a Class One Instrument Rating and this rating had been renewed after a flight test on 2 April, 1969. His total flying experience amounted to 5427 hours and of this, 966 hours had been flown on Aero Commander aircraft. He had recorded totals of 335 hours of instrument flying and 292 hours of night flying. The aircraft was operating under a current certificate of airworthiness and there is no evidence to indicate that the aircraft was other than in an airworthy condition. There is no evidence that the gross weight of the aircraft and the position of the centre of gravity were other than within the specified limits throughout the flight. The weather at Warracknabeal at the time of the accident was fine. There was no cloud and the wind was from the south east at 10 to 15 knots. The night visibility, that is, the distance at which prominent lighted objects could be seen and recognised, was reported to be 20 miles but it was a very dark night and there was virtually no visible horizon. The aircraft departed Essendon at 1836 hours using the procedures applicable to flight under the Instrument Flight Rules. The night to Warracknabeal at 6,500 feet was uneventful and the pilot commenced descent when the aircraft was approximately 40 miles from that destination. During the descent he observed the lights of the town of Warracknabeal and the lighting at the aerodrome. After entering the circuit the pilot commenced a downwind leg for a landing towards the east on runway 08. He made a left turn onto base leg and noted the indicated altitude as 1, 000 feet and at that altitude the clearance between the aircraft and the local terrain should have been slightly more than 600 feet. On the base leg of the circuit the pilot was unable to see the runway lights and being unsure of his position, he elected to conduct a go around. He did not retract the undercarriage, which had been extended earlier in preparation for landing, and the pilot continued the second circuit at 1, 000 feet indicated altitude rather than climbing to establish 1, 000 feet terrain clearance which would have been the normal procedure. He flew over the non-directional beacon, which is located approximately 300 yards north of the western end of the runway on which he intended to land arid he then positioned the aircraft for the downwind leg of the circuit.
Probable cause:
The probable cause of the accident was that the pilot, in approaching an aerodrome at night, did not use appropriate circuit procedures and did not make full use of the available visual and instrument information to ensure adequate terrain clearance.
Final Report: