Crash of a Cessna 414 Chancellor off Sydney: 2 killed

Date & Time: Aug 5, 2010 at 2337 LT
Type of aircraft:
Operator:
Registration:
C-GENG
Flight Type:
Survivors:
No
Schedule:
Butonville - Sydney
MSN:
414-0288
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
9677
Circumstances:
The privately owned Cessna 414A departed Toronto/Buttonville Municipal Airport, Ontario, en route to Sydney, Nova Scotia. The flight was operating under an instrument flight rules flight plan with the pilot-in-command and the aircraft owner on board. Nearing Sydney, the aircraft was cleared to conduct an instrument approach. At the final approach waypoint the pilot was advised to discontinue the approach due to conflicting traffic. While manoeuvring for a second approach, the aircraft departed from controlled flight, entered a rapid descent and impacted the water at 2335 Atlantic Daylight Time. The aircraft wreckage was located using a side-scan sonar 11 days later, in 170 feet of water. The aircraft had been destroyed and both occupants were fatally injured. No signal was detected from the emergency locator transmitter.
Probable cause:
Findings as to Causes and Contributing Factors:
1. It is likely that the PIC and the owner were both suffering some degree of spatial disorientation during the final portion of the flight. This resulted in a loss of control of the aircraft and the crew was unable to recover prior to contacting the surface of the water.
2. The PIC did not accept assistance in the form of radar vectors, which contributed to the workload during the approach.
3. Self-imposed pressure likely influenced the crew’s decision to depart Buttonville despite the flight conditions, lengthy day, and lack of experience with the aircraft and the destination airport.
Other Findings:
1. It could not be conclusively determined who was flying the aircraft at the time of the occurrence.
2. The lack of onboard recording devices prevented the investigation from determining the reasons why the aircraft departed controlled flight.
3. The practice of placing aircraft technical records on board aircraft may impede an investigation if the records are lost due to an accident.
Final Report:

Crash of a Swearingen SA227AC Metro III off Sydney, Australia: 1 killed

Date & Time: Apr 9, 2008 at 2327 LT
Type of aircraft:
Operator:
Registration:
VH-OZA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sydney-Brisbane
MSN:
AC-600
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4873
Captain / Total hours on type:
175.00
Aircraft flight hours:
32339
Aircraft flight cycles:
46710
Circumstances:
Shortly after takeoff at night, the pilot followed a wrong track outbound for Brisbane. ATC requested the reasons of that route change and the pilot reported minor technical problem. The twin engine aircraft eventually crashed in sea 8 km off Bundeena. The pilot was killed in the accident.
Probable cause:
Contributing safety factors
• It was very likely that the aircraft’s alternating current electrical power system was not energised at any time during the flight.
• It was very likely that the aircraft became airborne without a functioning
primary attitude reference or autopilot that, combined with the added workload
of managing the "slight technical fault", led to pilot spatial disorientation and
subsequent loss of control.Other safety factors
• The pilot’s Metro III endorsement training was not conducted in accordance
with the operator’s approved training and checking manual , with the result that
the pilot’s competence and ultimately, safety of the operation could not be
assured. [Significant safety issue]
• The chief pilot was performing the duties and responsibilities of several key positions in the operator’s organisational structure, increasing the risk of
omissions in the operator’s training and checking requirements.
• The conduct of the flight single-pilot increased the risk of errors of omission,
such as not turning on or noticing the failure of aircraft items and systems, or
complying with directions.

Crash of an Embraer EMB-110P1 Bandeirante in Cootamundra

Date & Time: Jun 25, 2001 at 1021 LT
Operator:
Registration:
VH-OZG
Survivors:
Yes
Schedule:
Sydney – Griffith
MSN:
110-241
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6850
Captain / Total hours on type:
253.00
Circumstances:
The Embraer EMB-110P1 Bandeirante, VH-OZG, departed from Sydney Kingsford Smith international airport at 0855 on 25 June 2001, on a single-pilot instrument flight rules (IFR) charter flight to Griffith. The nine occupants on board the aircraft included the pilot and eight passengers. At about 0945, while maintaining an altitude of 10,000 ft, the master caution light illuminated. At the same time, the multiple alarm panel ‘GENERATOR 2’ (right generator) warning light also illuminated, indicating that the generator was no longer supplying power to the main electrical bus bar. After resetting the generator and monitoring its output, the pilot was satisfied that it was operating normally. A short time later, the master warning light illuminated again. A number of circuit breakers tripped, accompanied by multiple master alarm panel warnings. The red ‘FIRE’ warning light on the right engine fire extinguisher ‘T’ handle also illuminated, accompanied by the aural fire alarm warning. The pilot reported that after silencing the aural fire alarm, he carried out the engine fire emergency checklist actions. However, he was unable to select the fuel cut-off position with the right fuel condition lever, despite overriding the locking mechanism using his left thumb while attempting to operate the lever with his right hand. He also reported that the propeller lever did not remain in the feathered detent, but moved forward, as if spring-loaded, to an intermediate position. After unsuccessfully attempting to select fuel cut-off with the right fuel condition lever, or feather the right propeller with the propeller lever, the pilot pulled the right ‘T’ handle to discharge the fire bottle. The amber discharge light illuminated and a short time later the fire alarm sounded again. Passengers reported seeing lights illuminated on the multiple alarm panel and heard the sound of a continuous fire alarm in the cockpit. At 0956, the pilot notified air traffic services (ATS) that there was a ‘problem’ with the aircraft, but did not specify the nature of that problem. Almost immediately the pilot transmitted a PAN radio call and advised ATS that there was a fire on board the aircraft. The nearest aerodromes for an emergency landing were not available due to fog, and the pilot decided to divert to Young, which was about 35 NM to the south east of the aircraft’s position at that time. The pilot advised ATS that the fire was extinguished, and that he was diverting the aircraft to Young. Two minutes later, the pilot repeated his advice to ATS stating that a fire in the right engine had been extinguished, and requested emergency services for the aircraft’s arrival at Young. The pilot informed one of the passengers that there was an engine fire warning, and that they would be landing at Young. The passengers subsequently reported seeing flames in the right engine nacelle and white smoke streaming from under the wing. Smoke had also started to enter the cabin in the vicinity of the wing root. The pilot subsequently reported that he had selected the master switch on the air conditioning control panel to the ‘vent’ position, and that he had opened the left direct vision window in an attempt to eliminate smoke from the cabin. When that did not appear to have any effect he closed the direct vision window. The pilot of another aircraft reported to ATS that Young was clear, but there were fog patches to the north. On arrival at Young, however, the pilot of the Bandeirante was unable to land the aircraft because of fog, and advised ATS that he was proceeding to Cootamundra, 27 NM to the south southwest of Young. The crew of an overflying airliner informed ATS that Cootamundra was clear of fog. ATS confirmed that advice by telephoning an aircraft operator at Cootamundra aerodrome. At 1017 thick smoke entered the cabin and the pilot transmitted a MAYDAY. He reported that the aircraft was 9 NM from Cootamundra, and ATS informed him that the aerodrome was clear of fog. The pilot advised that he was flying in visual conditions and that there was a serious fire on board. No further radio transmissions were heard from the aircraft. At 1021, approximately 25 minutes after first reporting a fire, the pilot made an approach to land on runway 16 at Cootamundra. He reported that when he selected the landing gear down on late final there was no indication that the gear had extended. The pilot reported that he did not have sufficient time to extend the gear manually using the emergency procedure because he was anxious to get the aircraft on the ground as quickly as possible. Unaware that the right main landing gear had extended the pilot advised the passengers to prepare for a ‘belly’ landing. He lowered full flap, selected the propeller levers to the feathered position and the condition levers to fuel cut-off. The aircraft landed with only the right main landing gear extended. The right main wheel touched down about 260 m beyond the runway threshold, about one metre from the right edge of the runway. During the landing roll the aircraft settled on the nose and the left engine nacelle and skidded for approximately 450 m before veering left off the bitumen. The soft grass surface swung the aircraft sharply left, and it came to a stop on the grass flight strip east of the runway, almost on a reciprocal heading. The pilot and passengers were uninjured, and vacated the aircraft through the cabin door and left overwing emergency exit. Personnel from a maintenance organisation at the aerodrome extinguished the fire in the right engine nacelle using portable fire extinguishers.
Probable cause:
Significant factors:
1. Vibration from the worn armature shaft of the right starter generator resulted in a fractured fuel return line.
2. The armature shaft of the right engine starter generator failed in-flight.
3. Sparks or frictional heat generated by the failed starter generator ignited the combustible fuel/air mixture in the right engine accessory compartment.
4. Items on the engine fire emergency checklist were not completed, and the fire was not suppressed.
5. The operator’s CASA approved emergency checklist did not contain smoke evacuation procedures.
6. The pilot did not attempt to extend the landing gear using the emergency gear extension when he did not to get a positive indication that the gear was down and locked.
7. The aircraft landed on the right main landing gear and slid to a stop on the right main gear, left engine nacelle and nose.
Final Report:

Crash of a Mitsubishi MU-2B-30 Marquise in Melbourne: 1 killed

Date & Time: Dec 21, 1994 at 0324 LT
Type of aircraft:
Registration:
VH-IAM
Flight Type:
Survivors:
No
Schedule:
Sydney – Melbourne
MSN:
517
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5000
Captain / Total hours on type:
150.00
Circumstances:
The aircraft departed Sydney for Melbourne International airport at 0130 on 21 December 1994. En-route cruise was conducted at flight level 140. Melbourne Automatic Terminal Information Service (ATIS) indicated a cloud base of 200 feet for the aircraft's arrival and runway 27 with ILS approaches, was in use. Air Traffic Control advised the pilot of VH-UZB, another company MU2 that was also en-route from Sydney to Melbourne, and the pilot of VH-IAM while approaching the Melbourne area, that the cloud base was at the ILS minimum and that the previous two aircraft landed off their approaches. VH-UZB was slightly ahead of VH-IAM and made a 27 ILS approach and landed. In response to an inquiry from the Tower controller the pilot of VH-UZB then advised that the visibility below the cloud base was 'not too bad'. This information was relayed by the Tower controller to the pilot of VH-IAM, who was also making a 27 ILS approach about five minutes after VH-UZB. The pilot acknowledged receipt of the information and was given a landing clearance at 0322. At 0324 the Approach controller contacted the Tower controller, who had been communicating with the aircraft on a different frequency, and advised that the aircraft had faded from his radar screen. Transmissions to VH-IAM remained unanswered and search-and-rescue procedures commenced. Nothing could be seen of the aircraft from the tower. A ground search was commenced but was hampered by the darkness and reduced visibility. The terrain to the east of runway 27 threshold, in Gellibrand Hill Park, was rough, undulating and timbered. At 0407 the wreckage was found by a police officer. Due to the darkness and poor visibility the policeman could not accurately establish his position. It took approximately another 15-20 minutes before a fire vehicle could reach the scene of the burning aircraft. The fire was then extinguished.
Probable cause:
The following factors were reported:
1. The company's training system did not detect deficiencies in the pilot's instrument flying skills.
2. The cloud base was low at the time of the accident and dark night conditions prevailed.
3. The pilot persisted with an unstabilised approach.
4. The pilot descended, probably inadvertently, below the approach minimum altitude.
5. The pilot may have been suffering from fatigue.
Final Report:

Crash of a PZL-Mielec AN-2R near Bayan

Date & Time: Sep 21, 1991
Type of aircraft:
Operator:
Registration:
HA-MEV
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Berlin - Sydney
MSN:
1G194-29
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed Berlin on July 26, taking part to an international Rally to Sydney, Australia. Already 40 en route stops were completed and few minutes after his departure from Bima Airstrip, the crew encountered engine problems and elected to make an emergency landing when the aircraft crash landed near Bayan, Lombok. All seven occupants escaped with minor injuries and the aircraft was damaged beyond repair.
Probable cause:
The engine caught fire in flight for unknown reasons. Brand new, the engine was changed prior to departure from Berlin.

Crash of a Beechcraft 65-B80 Queen Air in Tolmie: 1 killed

Date & Time: Jul 6, 1989 at 0341 LT
Type of aircraft:
Operator:
Registration:
VH-XAE
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sydney - Melbourne
MSN:
LD-305
YOM:
1966
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
At 0341 hours EST on 6 July 1989, Beechcraft 80 Queen Air aircraft registered VH-XAE collided with high voltage power lines and descended rapidly, contacting the ground three kilometres north-east of Tolmie. The pilot, who was the only occupant, received fatal injuries. There was no fire. The aircraft was on a flight from Sydney to Melbourne cruising at 8000 feet. Persons in the accident area heard an aircraft flying very low over their houses, then observed a flash of light and heard the sound of ground impact. A ground search was commenced but due to falling snow and very poor visibility the wreckage was not found until about 0745 hours in daylight. The elevation of the ground at the accident site was approximately 2,700 feet above sea level.
Probable cause:
The exact cause of the accident could not be determined.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) off Wollongong: 1 killed

Date & Time: Apr 2, 1989 at 1030 LT
Operator:
Registration:
VH-NOE
Flight Type:
Survivors:
No
Schedule:
Sydney - Wollongong
MSN:
61-0849-8162154
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot was to conduct a charter with passengers from Sydney to Wollongong, Nowra, Canberra and return to Sydney, departing Sydney at about 10.00am. Earlier that morning he positioned the aircraft at Sydney and had it refuelled. When the passengers arrived he explained that the weather in the various destinations was very poor and that there was a possibility they may not be able to land. However, he was prepared to give it a try. As the passengers were pressed for time, they could not afford to take a chance with the weather and so they decided to drive. They told the pilot that if he could land at Wollongong later that day they would continue the flight with him. However, they impressed on him that there was no pressure for him to depart immediately as they would not be in Wollongong for several hours. After driving for a short time, the passengers decided that the weather did not appear as if it would improve, and believed that it would be better to complete the journey by car. They contacted the charter company by phone to cancel the charter, but the pilot had already departed. The flight to Wollongong appears to have proceeded normally where the pilot reported commencing an NDB approach, and would call again at a specified time. This was the last message received from the pilot. Witnesses on the ground at Wollongong, and on a yacht 20 nautical miles to the east of Wollongong reported hearing an aircraft flying at approximately 1000 to 2000 feet in the low cloud and rain. There were no other known aircraft in the area. Later that day a helicopter discovered wreckage debris in the sea, which was confirmed as being from the aircraft. The search was discontinued due to very poor weather and visibility, and cancelled two weeks later when further efforts failed to locate any trace of the aircraft.
Probable cause:
The reason why the aircraft flew into the sea could not be determined.
Final Report:

Crash of a Rockwell Shrike Commander 500S off Norfolk Island: 1 killed

Date & Time: Sep 11, 1984
Operator:
Registration:
N9031N
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Pago Pago – Norfolk Island – Sydney
MSN:
500-1867-43
YOM:
1969
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
After takeoff from Norfolk Island Airport, while climbing, the twin engine aircraft lost height and crashed into the sea. The pilot, sole on board, was killed.

Crash of a Cessna 340A in Goulburn: 1 killed

Date & Time: May 15, 1979 at 1851 LT
Type of aircraft:
Operator:
Registration:
VH-TDU
Flight Phase:
Survivors:
Yes
Schedule:
Melbourne – Ballarat – Bendigo – Albury – Goulburn – Sydney
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3500
Copilot / Total flying hours:
1060
Copilot / Total hours on type:
3
Circumstances:
The pilot contacted Sydney Flight Service Center at 1849, advised he was taxiing for runway 22 and that he would call again on departure. No further transmissions were received from the aircraft. VH-TDU completed an apparently normal take off and the landing gear was retracted. Shortly after it became airborne, it entered a gradual descending left turn and flew into the ground. The initial impact was on the left wing tip, approximately 1700 metres south of the departure end of Runway 22, at a speed of about 125 knots. The aircraft bounced, rolled inverted and again struck the ground some 100 metres further to the east. It then ;slid across the ground for a further 230 metres. A small fuel-fed fire broke out in the right wing but died out after several minutes. Five occupants were slightly injured while the captain was killed. Examination of the wreckage found no evidence of pre-existing mechanical malfunction or defect, apart from an open circuit in the gyro motor of the pilot's turn co-ordinator instrument. The instrument was not subjected to mechanical damage during impact and it is likely the fault existed prior to the accident. It could not be determined whether the pilot was aware that the instrument was unserviceable. All other instruments, including the primary flight instruments used in aircraft attitude control, were found to be serviceable and calibrated within specified limits. There was no evidence of pilot incapacitation prior to impact. Injuries were such that he was unable to recall details of the final flight. The passengers were not aware of any abnormality until the aircraft struck the ground. The pilot's current log book was not located. Therefore, while it is known that he had considerable experience at flying Cessna 340 aircraft, his hours on this type are unknown.
Probable cause:
There is insufficient evidence to establish the cause of the accident but the most likely explanation is that the pilot, influenced by fatigue, did not adequately refer to the flight instruments during the take-off and initial climb.
Final Report:

Crash of a Noorduyn Norseman off Sydney

Date & Time: Jan 18, 1970
Type of aircraft:
Registration:
VH-GSF
Flight Phase:
Survivors:
Yes
MSN:
270
YOM:
1943
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The engine failed and burst into flames during a skydiving display off Manly Beach, northeast of Sydney. Eight parachutists baled out, followed by pilot Ken Andrews (owner of Skyservice Aviation) at 5,000 feet who was wearing a parachute. As he floated down under his parachute the circling Norseman came very close to hitting him. All were rescued by boats. The Norseman struck the sea 6 miles off the beach, 5 miles southeast off Sydney Heads.
Souce: Geoff Goodall
Probable cause:
Engine failure in flight.