Crash of a Cessna 421C Golden Eagle III off Sunshine Coast
Date & Time:
Nov 10, 2023 at 0907 LT
Operator:
Registration:
VH-VPY
Survivors:
Yes
Schedule:
Sunshine Coast - Pago Pago
MSN:
421C-0688
YOM:
1979
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Copilot / Total hours on type:
100
Circumstances:
On the morning of 10 November 2023, a Cessna 421C, registered VH-VPY, departed the Sunshine Coast Airport, Queensland for a transpacific international ferry flight to Oakland, California in the United States. Two pilots were on board to conduct the flight, where the first leg was planned to stop at Pago Pago, American Samoa. The aircraft was configured with additional ferry fuel tanks to ensure sufficient fuel was available between the stops for the extended journey across the open ocean. Approximately 50 minutes after departure, the left engine failed and the pilots initiated a return to the Sunshine Coast. During the return leg the pilots identified that the aircraft was unable to maintain altitude and calculations based on the descent rate indicated they would be unable to reach the Sunshine Coast. The pilots notified air traffic control of their intention to ditch, who immediately engaged the national search and rescue service provider. After considering the configuration of the aircraft, the pilots elected not to follow the aircraft manufacturer’s guidance on ditching. They configured the aircraft to avoid a nose down attitude on touchdown and allowed their airspeed to slow before the aircraft contacted the water. Both occupants were uninjured and exited through the rear door. After deploying the emergency life raft, both pilots were retrieved by a rescue helicopter 32 minutes after ditching. The aircraft sank and was not recovered.
Probable cause:
Contributing factors:
- While flying over open water the left engine failed. The nature of the engine failure prevented the propeller from feathering and the excess drag from the windmilling propeller reduced the available performance of the aircraft.
- Following the engine failure, as it was not possible for the pilot to quickly jettison sufficient fuel from the ferry tank, the weight of that fuel further reduced aircraft performance, resulting in the aircraft ditching.
Other factor that increased risk:
- The aircraft was loaded in excess of the weight and balance limitations imposed by the special ferry flight permit, and in addition, an unapproved modification was made to the ferry fuel system. These actions removed the defences incorporated into the ferry permit approval process and increased the likelihood of an adverse outcome.
- Both pilots did not hold the appropriate approvals and ratings to conduct the ferry flight.
Other findings:
- The pilots were familiar with the survival equipment and were well prepared in the event of a ditching.
- While the pilot actions during the ditching were not consistent with the flight manual, the method utilized considered the aircraft configuration and its performance in the prevailing conditions. It could not be determined if this increased the likelihood of aircraft damage/breakup when compared to the manufacturer's procedure.
- Early communication between the pilots, air traffic control and the Australian Maritime Safety Authority’s Response Centre allowed rescue efforts to commence prior to ditching, increasing the chances of survival.
- While flying over open water the left engine failed. The nature of the engine failure prevented the propeller from feathering and the excess drag from the windmilling propeller reduced the available performance of the aircraft.
- Following the engine failure, as it was not possible for the pilot to quickly jettison sufficient fuel from the ferry tank, the weight of that fuel further reduced aircraft performance, resulting in the aircraft ditching.
Other factor that increased risk:
- The aircraft was loaded in excess of the weight and balance limitations imposed by the special ferry flight permit, and in addition, an unapproved modification was made to the ferry fuel system. These actions removed the defences incorporated into the ferry permit approval process and increased the likelihood of an adverse outcome.
- Both pilots did not hold the appropriate approvals and ratings to conduct the ferry flight.
Other findings:
- The pilots were familiar with the survival equipment and were well prepared in the event of a ditching.
- While the pilot actions during the ditching were not consistent with the flight manual, the method utilized considered the aircraft configuration and its performance in the prevailing conditions. It could not be determined if this increased the likelihood of aircraft damage/breakup when compared to the manufacturer's procedure.
- Early communication between the pilots, air traffic control and the Australian Maritime Safety Authority’s Response Centre allowed rescue efforts to commence prior to ditching, increasing the chances of survival.
Final Report:
