Crash of a Grumman G-73 Mallard in Perth: 2 killed

Date & Time: Jan 26, 2017 at 1708 LT
Type of aircraft:
Operator:
Registration:
VH-CQA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Serpentine - Serpentine
MSN:
J-35
YOM:
1948
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
625
Captain / Total hours on type:
180.00
Circumstances:
On 26 January 2017, the pilot of a Grumman American Aviation Corp G-73 amphibian aircraft, registered VH-CQA (CQA), was participating in an air display as part of the City of Perth Australia Day Skyworks event. On board were the pilot and a passenger. The pilot of CQA was flying ‘in company’ with a Cessna Caravan amphibian and was conducting operations over Perth Water on the Swan River, that included low-level passes of the Langley Park foreshore. After conducting two passes in company, both aircraft departed the display area. The pilot of CQA subsequently requested and received approval to conduct a third pass, and returned to the display area without the Cessna Caravan. During positioning for the third pass, the aircraft departed controlled flight and collided with the water. The pilot and passenger were fatally injured.
Probable cause:
From the evidence available, the following findings are made regarding the loss of control and collision with water involving the G-73 Mallard aircraft, registered VH-CQA 10 km west-south-west of Perth Airport, Western Australia on 26 January 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual. Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.
Contributing factors:
- The pilot returned the aircraft to the display area for a third pass in a manner contrary to the approved inbound procedure and which required the use of increased manoeuvring within a confined area to establish the aircraft on the display path.
- During the final positioning turn for the third pass, the aircraft aerodynamically stalled at an unrecoverable height.
- The pilot's decision to carry a passenger on a flight during the air display was contrary to the Instrument of Approval issued by the Civil Aviation Safety Authority for this air display and increased the severity of the accident consequence.
Final Report:

Crash of a Beechcraft 200 Super King Air in Perth

Date & Time: Apr 9, 2007 at 1703 LT
Operator:
Registration:
VH-SGT
Survivors:
Yes
Schedule:
Perth - Mount Hale
MSN:
BB-73
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 9 April 2007, at 1703 Western Standard Time (WST), the main landing gear from a Beech Super King Air 200 aircraft, registered VH-SGT, collapsed on landing at Perth airport. Approximately two hours earlier, the aircraft was chartered to fly from Perth to Mount Hale, WA when shortly after takeoff from Perth the aircraft experienced a malfunction of the landing gear system. The main wheels and nose gear had become jammed and were unable to fully retract when selected up by the pilot. The pilot completed the emergency checklist actions contained in the Aircraft Flight Manual, but was unable to retract or extend the gear using either the automated control or the manual emergency system. The pilot then requested assistance from a passenger to operate the manual emergency extension system. The landing gear remained jammed despite the additional force applied to the lever from the passenger. The pilot contacted air traffic services and requested further assistance from company engineering personnel to visually assess the extension state of the landing gear. Two aerodrome passes were completed throughout the troubleshooting exercise and the pilot remained in radio contact with both groups during this phase. Following the flyovers and after holding over Rottnest Island at 5,000 ft for a period of approximately two hours, the pilot flew the King Air back to Perth airport. With the gear still jammed in the partially retracted position, both the left and right main landing gear assemblies collapsed after the aircraft touched down on Runway 24. The aircraft was substantially damaged as a result of the collapse (Figure 1). The airport Rescue and Fire Fighting (RFF) services and other relevant agencies had been alerted and were waiting in response when the King Air landed. No injuries were sustained by the pilot or any of the nine passengers on board.
Probable cause:
From the evidence available, the investigation revealed that two major system components had failed which could have prevented the Beechcraft Super King Air 200 landing gear from properly retracting after takeoff. The following findings with respect to those failed landing gear system components should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing safety factors:
• The left torque tube support bearing had not been lubricated and had seized due to the accumulation of dirt and grit contaminants that had migrated from the external service environment and into the bearing.
• The geared components within the right main landing gear actuator prematurely failed.
Other safety factors:
• The aircraft manufacturer’s maintenance manual contained insufficient instruction or guidance for operators and maintainers of Super King Air 200 aircraft for the lubrication of the landing gear torque tube support bearings.
Other key findings:
• Both component assemblies were integral to the function and normal operation of the Super King Air 200 mechanical landing gear system. A break down of either component assembly would have prevented any attempt by the pilot to retract or extend the aircraft’s main landing gear. However, while either failure could have produced the landing gear difficulties sustained, the investigation was not able to determine which mechanism was the principal contributor to the event.
• The investigation was unable to conclusively establish why the geared components within the right main landing gear actuator had prematurely failed.
• The lower thrust bearing within the right main landing gear actuator had been correctly installed.
Final Report:

Crash of a Partenavia P.68B Victor off Rottnest Island

Date & Time: Nov 12, 2006 at 1500 LT
Type of aircraft:
Operator:
Registration:
VH-IYK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Rottnest Island - Perth
MSN:
138
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Rottnest Island Airport, while in initial climb, the twin engine aircraft suffered a bird strike and crashed in a salt lake located near the airport. The aircraft was destroyed upon impact and all six occupants were injured.
Probable cause:
Loss of control during initial climb following a bird strike.

Crash of a Beechcraft 200 Super King Air in Wernadinga Station: 8 killed

Date & Time: Sep 4, 2000 at 1510 LT
Operator:
Registration:
VH-SKC
Flight Phase:
Survivors:
No
Schedule:
Perth - Leonora
MSN:
BB-47
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
2053
Captain / Total hours on type:
138.00
Aircraft flight hours:
18771
Circumstances:
On 4 September 2000, a Beech Super King Air 200 aircraft, VH-SKC, departed Perth, Western Australia at 1009 UTC on a charter flight to Leonora with one pilot and seven passengers on board. Until 1032 the operation of the aircraft and the communications with the pilot appeared normal. However, shortly after the aircraft had climbed through its assigned altitude, the pilot’s speech became significantly impaired and he appeared unable to respond to ATS instructions. Open microphone transmissions over the next 8-minutes revealed the progressive deterioration of the pilot towards unconsciousness and the absence of any sounds of passenger activity in the aircraft. No human response of any kind was detected for the remainder of the flight. Five hours after taking off from Perth, the aircraft impacted the ground near Burketown, Queensland, and was destroyed. There were no survivors.
Probable cause:
Due to the limited evidence available, it was not possible to draw definitive conclusions as to the factors leading to the incapacitation of the pilot and occupants of VH-SKC.
The following findings were identified:
1. The pilot was correctly licensed, had received the required training, and there was no evidence to suggest that he was other than medically fit for the flight.
2. The weather conditions on the day presented no hazard to the operation of the aircraft on its planned route.
3. The flightpath flown was consistent with the aircraft being controlled by the autopilot in heading and pitch-hold modes with no human intervention after the aircraft passed position DEBRA.
4. After the aircraft climbed above the assigned altitude of FL250, the speech and breathing patterns of the pilot, evidenced during the radio transmissions, displayed changes consistent with hypoxia.
5. Testing revealed that Carbon Monoxide and Hydrogen Cyanide were highly unlikely to have been factors in the occurrence.
6. The low Carbon Monoxide and Cyanide levels, and the absence of irritation in the airways of the occupants indicated that a fire in the cabin was unlikely.
7. The incapacitation of the pilot and passengers was probably due to hypobaric hypoxia because of the high cabin altitude and their not receiving supplemental oxygen.
8. A rapid or explosive depressurisation was unlikely to have occurred.
9. The reasons for the pilot and passengers not receiving supplemental oxygen could not be determined.
10. Setting the visual alert to operate when the cabin pressure altitude exceeds 10,000 ft and incorporating an aural warning in conjunction with the visual alert, may have prevented the accident.
11. The training and actions of the air traffic controller were not factors in the accident.
Significant factors:
1. The aircraft was probably unpressurised for a significant part of its climb and cruise for undetermined reasons.
2. The pilot and passengers were incapacitated, probably due to hypobaric hypoxia, because of the high cabin altitude and their not receiving supplemental oxygen.
Final Report:

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-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 Swearingen SA226TC Metro II in Esperance

Date & Time: May 13, 1980 at 0745 LT
Type of aircraft:
Operator:
Registration:
VH-SWO
Survivors:
Yes
Schedule:
Perth - Esperance
MSN:
TC-275
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9010
Captain / Total hours on type:
1155.00
Circumstances:
Weather conditions at Esperance were fine; there was no cloud, visibility was in excess of 30 km and the surface wind was from the northwest at 5 to 10 knots. The aircraft entered the circuit on a left downwind leg for an approach to Runway 29. The flaps were lowered, firstly a quarter and then half-way, on the downwind leg and the landing gear was extended just before the aircraft turned onto a base leg. This configuration, and an airspeed of 133 knots (best single - engine rate of climb speed), was maintained until after the aircraft was straightened onto final approach. At an altitude of 1100 feet, the pilot considered he was at Decision Height and committed to land. He lowered full flaps and reduced the airspeed to 115 knots. At about this time, as he was retarding the power levers, the right engine flamed out. The pilot reported that he promptly sensed the engine failure and checked the engine instruments while re-opening both power levers. He noted both torque and fuel flow indication s for the right engine were zero. He briefly considered retracting the landing gear and flaps but decided to do neither. Left engine power was increased initially to the maximum available of 940°C ITT (Inter-turbine temperature) and then adjusted to the normal maximum limit of 923°C ITT. The right propeller was feathered. During this period the aircraft banked to the right and turned away from the runway. Its airspeed had reduced and the rate of descent increased. The turn had been opposed but the pilot found that the application of full left rudder and aileron would not enable him to maintain runway heading, although the airspeed was above the minimum control airspeed of 94 knots, specified in the aircraft flight manual. It was evident to the pilot that the aircraft would land short of the aerodrome, amongst trees to the right of the runway approach path. He therefore abandoned his efforts to regain the normal approach path and allowed the aircraft to turn further to the right, towards a large, clear paddock. Just before touchdown, he observed a power pole on his selected landing path and he again turned further right to avoid it. During this turn the right wing tip struck the ground. The nosegear then impacted heavily and collapsed . The aircraft slid and bounced across the ground for 188 metres before coming to rest. Fuel from ruptured line s ignite d under the left engine , but the fire was slow to develop and the occupants were able to make an orderly evacuation . By the time the fire brigade arrived from Esperance township, the fire had spread and most of the aircraft was consumed.
Probable cause:
The right engine had flamed out because of fuel starvation, when a spur gear in the fuel control drive train failed. Five teeth of the spur gear had broken off and the remaining teeth were badly worn. The failures and abnormal wear were due to looseness of the torque sensor housing, in which the spur gear was mounted, allowing the gear to move out of its correct alignment. The housing had probably loosened because of vibration, as its natural frequency was close to some frequencies generated by the engine during normal operation. The following contributing factors were reported:
- The natural frequency of the torque sensor housings in the engines fitted to VH-SWO were susceptible to vibration frequencies generated by the engines during normal operation,
- Vibration loosened the torque sensor housing on the right engine, which in turn led to misalignment of a spur gear in the fuel drive train, failure of the gear and fuel starvation
of the engine,
- The engine failed when the aircraft was being operated in a landing configuration which precluded a successful continuation of the landing approach,
- The landing procedure used by the pilot was in accordance with the operator's Company Operations Manual, which did not appreciate the poor performance and handing' difficulties of the Swearingen SA226TC in the event of an engine failure in the landing configuration.
Final Report:

Crash of a Vickers 720 Viscount near Port Hedland: 26 killed

Date & Time: Dec 31, 1968 at 1135 LT
Type of aircraft:
Operator:
Registration:
VH-RMQ
Flight Phase:
Survivors:
No
Schedule:
Perth – Port Hedland
MSN:
45
YOM:
1954
Flight number:
MV1750
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
26
Captain / Total flying hours:
19129
Captain / Total hours on type:
367.00
Copilot / Total flying hours:
2660
Copilot / Total hours on type:
143
Circumstances:
Flight 1750 was a scheduled domestic flight from Perth to Port Hedland in the State of Western Australia. Whilst taxiing for take-off on runway 02 at Perth Airport, the crew received and acknowledged an air traffic clearance communicated by Perth Tower. Of the alternative clearances offered, the pilot-in-command elected to proceed via the 030° radial of the Perth Very High Frequency Omni-Range (VOR), to Ballidu, whilst climbing to FL 170. Take-off was normal and the crew reported the departure time as 0836 hours Western Standard Time. At 0839 hours the pilot-in-command reported that he was climbing at an indicated airspeed of 155 kt, instead of the 175 kt proposed in the flight plan, because of turbulence which he first encountered at 1 500 ft. During this climb the co-pilot also advised Perth that the aircraft would continue its climb beyond the proposed FL 170 and cruise at FL 190. Apart from these minor changes to the flight plan the aircraft continued normally along the intended route with position reports being transmitted as scheduled to Perth Flight Service Centre, Meekatharra Flight Service Unit and Port Hedland Flight Service Centre. At 1114 hours the aircraft advised Port Hedland that it was abeam Wittenoom Gorge at FL 190 and that its estimated time of arrival at Port Hedland was 1142 hours. At 1120 hours the flight advised that it would be commencing its descent from FL 190 in three minutes and at 11-34 hours it reported that it was 30 miles by Distance Measuring Equipment south of Port Hedland-and had left 7 000 ft on descent. The flight service officer at Port Hedland acknowledged this message and transmitted the surface wind and temperature conditions and the altimeter setting for landing at Port Hedland. When this communication was not acknowledged further calls were made but no further communication from the aircraft was heard or recorded. At about the time that the aircraft failed to respond to the radio communication, two persons, each in different positions, saw the aircraft descending rapidly and steeply although these observations were made from distances of 44 and 64 miles respectively. Neither of these eyewitnesses was able to observe any impact with the ground because of intervening high terrain. At 1212 hours a Cessna 337 aircraft left Port Hedland to search along the route which the aircraft had been expected to follow and, eleven minutes later, the pilot of the search aircraft saw the burning wreckage of the Viscount aircraft, close to the intended route. Approximately one hour later a ground party from Port Hedland reached the scene of the accident. The location of the wreckage was later determined to be 28.1 miles on a bearing of 184' true from Port Hedland Airport. The aircraft was totally destroyed and none of the 26 occupants survived the crash.
Probable cause:
The cause of the accident was that the fatigue endurance of the starboard inner main spar lower boom was substantially reduced by the insertion of a flared bush at station 143 when the margin of safety associated with the retirement life specified for such booms did not ensure that this boom would achieve its retirement life in the presence of such a defect.
Final Report:

Crash of an Avro 652 Anson I in Carnamah

Date & Time: Nov 7, 1952
Type of aircraft:
Operator:
Registration:
VH-AVS
Survivors:
Yes
Schedule:
Perth – Carnamah
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed on approach to Carnamah, while on a flight from Perth. Both occupants were injured and the aircraft was written off.

Crash of a De Havilland DH.104 Dove near Kalgoorlie: 7 killed

Date & Time: Oct 15, 1951 at 1520 LT
Type of aircraft:
Operator:
Registration:
VH-AQO
Survivors:
No
Schedule:
Perth – Kalgoorlie
MSN:
04002
YOM:
1946
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
While descending to Kalgoorlie, the twin engine aircraft went out of control, dove into the ground and crashed in a prairie located about 22 km west of Kalgoorlie, in the Kurrawang Natural Reserve. All seven occupants were killed, among them Captain Charles M. Hood and hostess/radio operator Dorothy Reilly.
Probable cause:
It was determined that the accident was caused by the physical loss of the left wing that detached in flight due to metal fatigue.