Crash of a Swearingen SA227AC Metro III off Sydney: 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 on board:
0
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:
On 9 April 2008, at 2325 Eastern Standard Time, a Fairchild Industries Inc. SA227-AC (Metro III) aircraft, registered VH-OZA, departed Sydney Airport, New South Wales on a freight charter flight to Brisbane, Queensland with one pilot on board. The aircraft was subsequently observed on radar to be turning right, contrary to air traffic control instructions to turn left to an easterly heading. The pilot reported that he had a ‘slight technical fault’ and no other transmissions were heard from the pilot. Recorded radar data showed the aircraft turning right and then left, followed by a descent and climb, a second right turn and a second descent before radar returns were lost when the aircraft was at an altitude of 3,740 ft above mean sea level and descending at over 10,000 ft/min. Air traffic control initiated search actions and search vessels later recovered a small amount of aircraft wreckage floating in the ocean, south of the last recorded radar position. The pilot was presumed to be fatally injured and the aircraft was destroyed. Both of the aircraft’s on-board flight recorders were subsequently recovered from the ocean floor. They contained data from a number of previous flights, but not for the accident flight. There was no evidence of a midair breakup of the aircraft.
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.
Final Report:

Crash of a Beechcraft B200C Super King Air in Coffs Harbour

Date & Time: May 15, 2003 at 0833 LT
Operator:
Registration:
VH-AMR
Flight Type:
Survivors:
Yes
Schedule:
Sydney – Coffs Harbour
MSN:
BL-126
YOM:
1985
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18638
Captain / Total hours on type:
460.00
Circumstances:
The aircraft impacted the sea or a reef about 6 km north-east of Coffs Harbour airport. The impact occurred immediately after the pilot initiated a go-around during an instrument approach to runway 21 in Instrument Meteorological Conditions (IMC) that included heavy rain and restricted visibility. Although the aircraft sustained structural damage and the left main gear detached, the aircraft remained airborne. During the initial go-around climb, the aircraft narrowly missed a breakwater and adjacent restaurant at the Coffs Harbour boat harbour. Shortly after, the pilot noticed that the primary attitude indicator had failed, requiring him to refer to the standby instrument to recover from an inadvertent turn. The pilot positioned the aircraft over the sea and held for about 30 minutes before returning to Coffs Harbour and landing the damaged aircraft on runway 21. There were no injuries or any other damage to property and/or the environment because of the accident. The aircraft was on a routine aeromedical flight from Sydney to Coffs Harbour with the pilot, two flight nurses, and a stretcher patient on board. The flight was conducted under instrument flight rules (IFR) in predominantly instrument meteorological conditions (IMC). During the descent, the enroute air traffic controller advised the pilot to expect the runway 21 Global Positioning System (GPS) non-precision approach (NPA). The pilot reported that he reviewed the approach diagram and planned a 3-degree descent profile. He noted the appropriate altitudes, including the correct minimum descent altitude (MDA) of 580 ft, on a reference card. A copy of the approach diagram used by the pilot is at Appendix A. The aerodrome controller advised the pilot of the possibility of a holding pattern due to a preceding IFR aircraft being sequenced for an instrument approach to runway 21. The controller subsequently advised that holding would not be required if the initial approach fix (SCHNC)2 was reached not before 0825. At about 0818, the aerodrome controller advised the pilot of the preceding aircraft that the weather conditions in the area of the final approach were a visibility of 5000 m and an approximate cloud base of 1,000 ft. At 0825 the aerodrome controller cleared the pilot of the King Air to track the aircraft from the initial approach fix to the intermediate fix (SCHNI) and to descend to not below 3,500 ft. The published minimum crossing altitude was 3,600 ft. About one minute later the pilot reported that he was leaving 5,500 ft and was established inbound on the approach. At 0828 the pilot reported approaching the intermediate fix and 3,500 ft. The controller advised that further descent was not available until the preceding aircraft was visible from the tower. At 0829 the controller, having sighted the preceding aircraft, cleared the pilot of the King Air to continue descent to 2,500 ft. The pilot advised the controller that he was 2.2 NM from the final approach fix (SCHNF). At that point an aircraft on a 3-degree approach slope to the threshold would be at about 2,500 ft. The controller then cleared the pilot for the runway 21 GPS approach, effectively a clearance to descend as required. The pilot subsequently explained that he was high on his planned 3-degree descent profile because separation with the preceding aircraft resulted in a late descent clearance. He had hand flown the approach, and although he recalled setting the altitude alerter to the 3,500 ft and 2,500 ft clearance limits, he could not recall setting the 580 ft MDA. He stated that he had not intended to descend below the MDA until he was visual, and that he had started to scan outside the cockpit at about 800 ft altitude in expectation of becoming visual. The pilot recalled levelling the aircraft, but a short time later experienced a 'sinking feeling'. That prompted him to go-around by advancing the propeller and engine power levers, and establishing the aircraft in a nose-up attitude. The passenger in the right front seat reported experiencing a similar 'falling sensation' and observed the pilot's altimeter moving rapidly 'down through 200 ft' before it stopped at about 50 ft. She saw what looked like a beach and exclaimed 'land' about the same time as the pilot applied power. The pilot felt a 'thump' just after he had initiated the go-around. The passenger recalled feeling a 'jolt' as the aircraft began to climb. Witnesses on the northern breakwater of the Coffs Harbour boat harbour observed an aircraft appear out of the heavy rain and mist from the north-east. They reported that it seemed to strike the breakwater wall and then passed over an adjacent restaurant at a very low altitude before it was lost from sight. Wheels from the left landing gear were seen to ricochet into the air and one of the two wheels was seen to fall into the water. The other wheel was found lodged among the rocks of the breakwater.During the go-around the pilot unsuccessfully attempted to raise the landing gear, so he reselected the landing gear selector to the 'down' position. He was unable to retract the wing flaps. It was then that he experienced a strong g-force and realised that he was in a turn. He saw that the primary attitude indicator had 'toppled' and referred to the standby attitude indicator, which showed that the aircraft was in a 70-degree right bank. He rapidly regained control of the aircraft and turned it onto an easterly heading, away from land. The inverter fail light illuminated but the pilot did not recall any associated master warning annunciator. He then selected the number-2 inverter to restore power to the primary attitude indicator, and it commenced to operate normally. The pilot observed that the left main landing gear had separated from the aircraft. He continued to manoeuvre over water while awaiting an improvement in weather conditions that would permit a visual approach. About 4 minutes after the King Air commenced the go-around, the aerodrome controller received a telephone call advising that a person at the Coffs Harbour boat harbour had witnessed an aircraft flying low over the harbour, and that the aircraft had '…hit something and the wheel came off'. The controller contacted the pilot, who confirmed that the aircraft was damaged. The controller declared a distress phase and activated the emergency response services to position for the aircraft's landing. Witnesses reported that the landing was smooth. As the aircraft came to rest on the runway, foam was applied around the aircraft to minimise the likelihood of fire. The occupants exited the aircraft through the main cabin door.
Probable cause:
This occurrence is a CFIT accident resulting from inadvertent descent below the MDA on the final segment of a non-precision approach, fortunately without the catastrophic consequences normally associated with such events. The investigation was unable to conclusively determine why the aircraft descended below the MDA while in IMC, or why the descent continued until CFIT could no longer be avoided. However, the investigation identified a number of factors that influenced, or had the potential to influence, the development of the occurrence.
Final Report:

Crash of a Douglas C-47A-20-DK off Sydney

Date & Time: Apr 24, 1994 at 0910 LT
Registration:
VH-EDC
Flight Phase:
Survivors:
Yes
Schedule:
Sydney - Norfolk Island - Lord Howe Island
MSN:
12874
YOM:
1944
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9186
Captain / Total hours on type:
927.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
250
Aircraft flight hours:
40195
Circumstances:
This accident involved a DC-3 aircraft which was owned and operated by South Pacific Airmotive Pty Ltd, who were based at Camden, NSW. It was flown on commercial operations under an Air Operators Certificate held by Groupair, who were based at Moorabbin, Vic. The aircraft had been chartered to convey college students and their band equipment from Sydney to Norfolk Island to participate in Anzac Day celebrations on the island. A flight plan, submitted by the pilot in command, indicated that the aircraft was to proceed from Sydney (Kingsford-Smith) Airport to Norfolk Island, with an intermediate landing at Lord Howe Island to refuel. The flight was to be conducted in accordance with IFR procedures, with a departure time from Sydney of 0900. The aircraft, which was carrying 21 passengers, was crewed by two pilots, a supernumerary pilot and a flight attendant. Preparations for departure were completed shortly before 0900, and the aircraft was cleared to taxi for runway 16 via taxiway Bravo Three. The pilot in command occupied the left control position. The co-pilot was the handling pilot for the departure. The aircraft was cleared for takeoff at 0907:53. The crew subsequently reported to the investigation team that all engine indications were normal during the take-off roll and that the aircraft was flown off the runway at 81 kts. During the initial climb, at approximately 200 ft, with flaps up and the landing gear retracting, the crew heard a series of popping sounds above the engine noise. Almost immediately, the aircraft began to yaw left and at 0909:04 the pilot in command advised the TWR that the aircraft had a problem. The co-pilot determined that the left engine was malfunctioning. The crew subsequently recalled that the aircraft speed at this time had increased to at least 100 kts. The pilot in command, having verified that the left engine was malfunctioning, closed the left throttle and initiated propeller feathering action. During this period, full power (48 inches Hg and 2,700 RPM) was maintained on the right engine. However, the airspeed began to decay. The handling pilot reported that he had attempted to maintain 81 KIAS but was unable to do so. The aircraft diverged to the left of the runway centreline. The co-pilot and the supernumerary pilot subsequently reported that almost full right aileron had been used to control the aircraft. They could not recall the skid-ball indication. The copilot reported that he had full right rudder or near full right rudder applied. When he first became aware of the engine malfunction, the pilot in command assessed that, although a landing back on the runway may have been possible, the aircraft was capable of climbing safely on one engine. However, when he determined that the aircraft was not climbing, and that the airspeed had reduced below 81 kts, the pilot in command took control, and at 0909:38 advised the TWR that he was ditching the aircraft. He manoeuvred the aircraft as close as possible to the southern end of the partially constructed runway 16L. The aircraft was ditched approximately 46 seconds after the pilot in command first advised the TWR of the problem. The four crew and 21 passengers successfully evacuated the aircraft before it sank. They were taken on board pleasure craft and transferred to shore. After initial assessment, they were transported to various hospitals. All were discharged by 1430 that afternoon, with the exception of the flight attendant, who had suffered serious injuries.
Probable cause:
The following factors were considered significant in the accident sequence.
1. Compliance with the correct performance charts would have precluded the flight.
2. Clear and unambiguous presentation of CAA EROPs documentation should have precluded the flight.
3. The aircraft weight at takeoff exceeded the MTOW, the extent of which was unknown to the crew.
4. An engine malfunction and resultant loss of performance occurred soon after takeoff.
5. The operations manual take-off safety speed used by the crew was inappropriate for the overloaded condition of the aircraft.
6. The available single-engine aircraft performance was degraded when the co-pilot mishandled the aircraft controls.
7. The pilot in command delayed taking over control of the aircraft until the only remaining option was to conduct a controlled ditching.
8. There were organisational deficiencies in the management and operation of the DC-3 involving both Groupair and SPA.
9. There were organisational deficiencies in the safety regulation of both Groupair and SPA by the CAA district offices at Moorabbin and Bankstown.
10. There were organisational deficiencies relating to safety regulation of EROPS by the CAA.
Final Report:

Crash of a Rockwell Grand Commander 690 off Sydney: 1 killed

Date & Time: Jan 14, 1994 at 0114 LT
Registration:
VH-BSS
Flight Type:
Survivors:
No
Schedule:
Canberra - Sydney
MSN:
690-11044
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1800
Captain / Total hours on type:
50.00
Aircraft flight hours:
7975
Circumstances:
On 14 January 1994 at 0114, Aero Commander 690 aircraft VH-BSS struck the sea while being radar vectored to intercept the Instrument Landing System approach to runway 34 at Sydney (Kingsford-Smith) Airport, NSW. The last recorded position of the aircraft was about 10 miles to the south-east of the airport. At the time of the accident the aircraft was being operated as a cargo charter flight from Canberra to Sydney in accordance with the Instrument Flight Rules. The body of the pilot who was the sole occupant of the aircraft was never recovered. Although wreckage identified as part of the aircraft was located on the seabed shortly after the accident, salvage action was not initially undertaken. This decision was taken after consideration of the known circumstances of the occurrence and of the costs of salvage versus the potential safety benefit that might be gained from examination of the wreckage. About 18 months after the accident, the wing and tail sections of the aircraft were recovered from the sea by fishermen. As a result, a detailed examination of that wreckage was carried out to assess the validity of the Bureau’s original analysis that the airworthiness of the aircraft was unlikely to have been a factor in this accident. No evidence was found of any defect which may have affected the normal operation of the aircraft. The aircraft descended below the altitude it had been cleared to by air traffic control. From the evidence available it was determined that the circumstances of this accident were consistent with controlled flight into the sea.
Probable cause:
Findings
1. The pilot held a valid pilot licence, endorsed for Aero Commander 690 aircraft.
2. The pilot held a valid multi-engine command instrument rating.
3. There was no evidence found to indicate that the performance of the pilot was adversely affected by any physiological or psychological condition.
4. The aircraft was airworthy for the intended flight, despite the existence of minor anomalies in maintenance and serviceability of aircraft systems.
5. The aircraft carried fuel sufficient for the flight.
6. The weight and balance of the aircraft were estimated to have been within the normal limits.
7. Recorded radio communications relevant to the operation of the aircraft were normal.
8. Relevant ground-based aids to navigation were serviceable.
9. At the time of impact the aircraft was capable of normal flight.
10. The aircraft was fitted with an altitude alerting system.
11. The aircraft was not fitted with a ground proximity warning system.
12. The aircraft was equipped with a transponder which provided aircraft altitude information to be displayed on Air Traffic Control radar equipment.
3.2 Significant factors
1. The pilot was relatively inexperienced in single-pilot Instrument Flight Rules operations on the type of aircraft being flown.
2. The aircraft was being descended over the sea in dark-night conditions.
3. The workload of the pilot was significantly increased by his adoption of a steep descent profile at high speed, during a phase of flight which required multiple tasks to be completed in a limited time prior to landing. Radio communications with another company aircraft during that critical phase of flight added to that workload.
4. The pilot probably lost awareness of the vertical position of the aircraft as a result of distraction by other tasks.
5. The aircraft was inadvertently descended below the altitude authorized by Air Traffic Control.
6. The secondary surveillance radar system in operation at the time provided an aircraft altitude readout which was only updated on every sixth sweep of the radar display.
7. The approach controller did not notice a gross change of aircraft altitude shortly after a normal radio communication with the pilot.
Final Report:

Crash of a Cessna 501 Citation I/SP in Lord Howe Island

Date & Time: Apr 22, 1990 at 1225 LT
Type of aircraft:
Operator:
Registration:
VH-LCL
Flight Type:
Survivors:
Yes
Schedule:
Sydney - Lord Howe
MSN:
501-0145
YOM:
1979
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was being used for a pleasure flight for the owner and some friends. The Captain calculated the landing distances required for both runway 28 and 10, based on weather reports obtained at briefing, which indicated a strong northerly wind component. An updated report received some 30 minutes before descent confirmed the wind as 290 degrees at 7 knots. Approaching the island and becoming visual, the crew noted the windsock near the western end of the runway to be indicating a slight headwind component in the 10 direction and decided on a straight in approach to runway 10, to avoid an approaching squall/shower. The aircraft touched down firmly a short distance beyond the threshold. Speed brakes were immediately extended and wheel braking applied. About four seconds later the Captain called for the drag chute to be deployed. Although the co-pilot correctly activated the handle, it became obvious that the chute had not deployed as no increase in retardation occurred. When the Captain realised that the aircraft could not be stopped on the runway remaining he attempted to turn the aircraft towards a clear grass area to the right. However, the aircraft was aquaplaning on the wet surface and did not respond to steering inputs for some distance. The aircraft left the bitumen tracking to the right. It collided with a gable marker, passed through a fence, continued down an embankment, across a road, through a second fence and came to rest approximately 90 metres from the runway end and 70 metres to the right of the extended centreline. The left main and nose gear legs were torn off. Witnesses to the accident said that when the aircraft landed, the runway was very wet and the wind was westerly at 5 to 10 knots.
Probable cause:
It was determined that the Captain had made some miscalculations in his pre-flight assessments. He had noted the landing distance available as being the same for both runways, whereas runway 28 has a reduced length due to terrain clearance requirements on the approach. Under the conditions both forecast and prevailing, and using the criteria applicable at the time for an aircraft fitted with an alternate means of retardation, i.e. drag chute, the landing distances required for both runways were greater than the landing distances available. The Captain had also evidently applied incorrect techniques during the landing. He had not attempted to deploy the drag chute immediately the nose wheel was on the ground, and had not applied unmodulated pressure to the anti-skid braking system. These measures are required by the manufacturer to obtain maximum performance. It was found that the drag chute canister lid had been sealed with tank sealant and painted over. The latch assembly had operated but the drogue chute spring was insufficiently strong to break the seal. When the sealant was prised away from around the lid, the system operated normally. This error had not been found during a check of the aircraft immediately following repainting. The lid had the appearance of an oblong radio antenna and was not marked in any distinguishing manner. The problem should also have been noticed during a subsequent inspection of the drag chute for moisture. The inspection is required every 90 days if the drag chute has
not been deployed, and requires the removal of the lid and drogue chute in order to feel the main chute for moisture. The condition of the sealant would indicate that this had not been carried out.
The following factors were considered relevant to the development of the accident:
- Inadequate pre-flight planning and preparation by the flight crew. The runway distance required was in excess of the distance available on either runway.
- Adverse runway and weather conditions - wet surface and downwind component.
- Improper sealing of drag chute canister.
- Inadequate maintenance of the drag chute system.
- Improper operation of wheel brakes.
Final Report:

Crash of an IAI 1124 Westwind off Sydney: 2 killed

Date & Time: Oct 10, 1985 at 0059 LT
Type of aircraft:
Operator:
Registration:
VH-IWJ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sydney – Brisbane – Cairns
MSN:
371
YOM:
1982
Flight number:
QH474
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
9881
Captain / Total hours on type:
3101.00
Copilot / Total flying hours:
8091
Copilot / Total hours on type:
500
Aircraft flight hours:
3105
Circumstances:
IAI 1124 Westwind aircraft, registered VH-IWJ, was operating under a current Certificate of Registration, the holder of which was Pel-Air Aviation Pty Ltd (Pe1-Air). The aircraft was operated by Pel-Air and, at the time of the accident, it was engaged on a regularly scheduled cargo service. This service was operated under the terms of a current Charter and Aerial Work Licence, and was flown on behalf of Ansett Air Freight, a subsidiary of Ansett Transport Industries Pty Ltd. The particular flight, designated Flight 474, was operated on 4 nights each week from Sydney to Brisbane and Cairns, Queensland. The aircraft had departed Cairns earlier in the evening and had flown via Brisbane to Sydney, arriving at 2336 hours. The arriving crew reported that the aircraft was performing normally. A total of 1,350 litres of fuel was added to the aircraft tanks and loading of general cargo was carried out by Ansett Air Freight personnel. The flight plan submitted to Air Traffic Control (ATC) indicated that the flight would follow the normal Instrument Flight Rules (IFR) procedures. The estimated time interval to Brisbane was 70 minutes at planned Flight Level 370 (approximate altitude of 37,000 feet). The aircraft carried sufficient fuel for 164 minutes of flight, and refuelling was planned to take place at Brisbane prior to departure for Cairns. Pel-Air intended to use the flight to assess the performance of the rostered co-pilot, who was being considered for upgrading to command status. He was to occupy the left hand control seat, while the right hand seat occupant was the Chief Pilot of the company. At 0033 hours the crew established radio contact on the Sydney ATC Clearance Delivery frequency, and were given a "16 West Maitland One" Standard Instrument Departure (SID). The flight pattern associated with this clearance requires the aircraft to maintain heading after take-off on Runway 16 until reaching a height of 500 feet, when a left turn is made to intercept the 126 radial of the Sydney VOR (Very High Frequency Omnidirectional Range). At a position of 6 nautical miles by Distance Measuring Equipment (DME) from the aerodrome, a left turn onto 357 degrees is made in order to continue tracking with reference to the West Haiti and VOR. A copy of the applicable SID chart is shown at Appendix A. Shortly before 0049 hours the crew contacted Sydney Control Tower, and the aircraft was directed to taxi for a departure from Runway 16. At the time the wind was light and variable. After receiving the appropriate clearance, an evidently normal take-off was made, and at 0056 hours contact was established with Sydney Departures Control. The pilot in command advised that the aircraft was on climb to Flight Level 370 , and requested the direct track to Brisbane. This was a standard request, to allow the aircraft to proceed directly to the destination rather than follow the various radio navigation aids along the route. Such a request was normally granted by ATC if the general traffic situation permitted use of the direct track, and provided the aircraft was equipped with a suitable navigation system. VH-IWJ was fitted with a VLF/Omega navigation system which was capable of direct tracking. After ascertaining this, the Departures controller advised the aircraft that the direct track to Brisbane would probably be available. The acknowledgment of this comment was the last recorded transmission from the aircraft. Shortly before 0059 hours the Departures controller broadcast the clearance for the aircraft to track direct to Brisbane at the planned cruising level. No response was received from the aircraft, although the controller noted that radar returns were still visible on his screen. Shortly afterwards, these returns faded, and the Distress Phase of Search and Rescue procedures was Instituted at 0100 hours. At about this time, a number of persons observed what appeared to be the lights of an aircraft descending rapidly towards the sea. The lights maintained their position relative to each other, indicating that the aircraft was not rotating as it descended. The aircraft had faded from the radar screen at a point about 11 kilometres south-east of Sydney Airport. A search of the area was commenced using helicopters and boats. Wreckage Identified as being from the aircraft was sighted by a helicopter at 0245 hours. Recovery of pieces of the aircraft structure, freight and human remains was effected by Police and Department of Aviation launches. The degree of destruction indicated that the aircraft had struck the water while travelling at high speed. The bulk of the wreckage was presumed to be lying in about 85 metres of water about 5 kilometres out to sea from Botany Bay. An Intensive search was carried out by vessels from the Royal Australian Navy, later assisted by a vessel from the NSW Department of Fisheries and Agriculture. Use was made of various underwater detection devices. Search efforts were hampered by persistent unfavourable sea conditions and no trace was found of the wreckage. Operations were finally suspended towards the end of November 1985. An Internationally recognised underwater location and salvage expert was then employed, and the wreckage was ultimately located and identified in 92 metres of water on 20 January 1986. Recovery of the Flight Data and Cockpit Voice Recorders, the major portions of both engines, and sundry other pieces of the aircraft structure, was effected the following month.
Probable cause:
The following findings were reported:
1.There was a known malfunction of the rate of turn indicator.
2. The pilot in command possibly simulated simultaneous failures of all three flight attitude indicators.
3. There were no external references by which the crew could assess the attitude of the aircraft.
4. A loss of control of the aircraft occurred at a height of about 5000 feet.
5. The crew did not recover control of the aircraft prior to impact with the sea.
Final Report:

Crash of a Beechcraft 200 Super King Air in Sydney: 13 killed

Date & Time: Feb 21, 1980 at 1909 LT
Operator:
Registration:
VH-AAV
Survivors:
No
Schedule:
Sydney – Temora – Condobolin
MSN:
BB-245
YOM:
1977
Flight number:
DR4210
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
13
Captain / Total flying hours:
6384
Captain / Total hours on type:
448.00
Aircraft flight hours:
5061
Circumstances:
The aircraft was engaged in a scheduled service, designated Flight DR 4210, from Sydney to Temora and Condobolin, within the State of New South Wales. The scheduled departure time was 1845 hours. At 1844 hours the pilot of VH-AAV contacted Sydney Airport Clearance Delivery by radio and requested his airways clearance. The airways clearance issued was a Standard Instrument Departure (SID), titled '25 Katoomba Two'. That SID specified that radar headings would be assigned after take-off from Runway 25. The pilot correctly acknowledged the airways clearance. At 1848 hours the pilot contacted Sydney Ground Control and requested clearance to· taxi. This was granted and the aircraft was taxied to the holding point for Runway 25. The pilot reported to Sydney Aerodrome Control at 1858 hours that he was ready for take-off. Due to other traffic. the aircraft was not cleared to line up until 1906 hours. VH-AAV then entered Runway 25 and stopped about 50 metres from the threshold. At 1907 hours VH-AAV was cleared to 'maintain runway heading, maintain 3000 (feet), clear for take-off. This was correctly acknowledged and VH-AAV commenced takeoff. The aircraft became airborne and crossed the intersection with Runway 16/34, at a height of about 100 feet above ground level (AGL) at 1908:19 hours. The landing gear was retracted. Observers then noted the aircraft level off at about 150 feet AGL and commence a shallow banked turn to the left. As this was contrary to the departure instructions, Aerodrome Control was about to query the pilot when, at 1908:33 hours. he advised: ' ... we've lost er, the left engine. Request landing, ah, landing on runway three four immediately please.' This was acknowledged and Aerodrome Control cleared VH-AAV for a visual approach to a left base for Runway 34. During these transmissions, VH-AAV continued its left turn through approximately 90 degrees, onto a southerly heading. It had maintained a height of about 150 feet AGL and the left propeller was probably in the process of feathering. At 1908:44 hours, Aerodrome Control queried' ... do you have the seven two seven in sight on short final.' At 1908:49 hours, the pilot of VH-AAV replied, 'Affirmative'. The other aircraft referred to by Aerodrome Control was an Ansett Airlines of Australia Boeing 727, VH-RMO, which was on approach for Runway 34. Shortly after passing over the shore of Botany Bay, VH-AAV entered a steady descent and then levelled off just above the water. The left turn was continued and the aircraft converged towards the western side of the sea wall enclosing the extension of Runway 16/34. At 1908:50 hours, Aerodrome Control asked,' ... will your approach and landing be normal.' The reply, eight seconds later, was 'Alpha Alpha Victor negative'. At 1909:08 hours, Aerodrome Control activated the crash alarm system. In addition, VH-RMO was directed' ... go around, correction, st ... stay on the runway and expedite. We have a landing, er, right behind you ... one engine out.' The initial direction was made prior to visually assessing the Boeing ?27's situation, but when, during the transmission, it was noted that the aircraft was on the ground and well established in its landing roll sequence, the 'expedite' instruction was substituted. At 1909:20 hours, Aerodrome Control cleared VH-AAV to land. This was not acknowledged. The final segment of the flight was at an extremely low altitude and in a nose-high attitude. The right propeller, on at least one occasion, probably contacted the water and the tail either furrowed the water or induced a wake. VH-AAV struck the sea wall in a nose-up attitude, banking to the left and skidding to the right. The left wing of the aircraft disintegrated. The resultant fuel spillage ignited and a 'fire ball' explosion occurred. The right engine and the outboard section or the right wing both separated and were thrown across the ground adjacent to the runway. The remainder of the aircraft bounced over the sea wall, landed inverted on a taxiway and slid backwards. The accident occurred in daylight at 1909:22 hours. The aircraft was totally destroyed by impact forces and a post crash fire and all 13 occupants were killed.
Probable cause:
The cause of the accident has not been determined, but the most likely explanation is that the aircraft was operated in a reduced power configuration which, under the prevailing conditions, rendered its single-engine performance critical in respect to aircraft handling. The following findings were reported:
- At a height of about 100 feet AGL the left engine failed, probably due to the ingestion of water-contaminated fuel,
- The source of water contamination of the left fuel system of VH-AAV was not established but elemental analyses indicated the water had been present in the fuel system for some time,
- It could
not be determined where the water in the left fuel system of VH-AAV had accumulated or by what means it traveled to the left engine,
- It was not established whether or not the pilot had carried out a fuel drain check prior to the accident flight,
- At the time of engine failure, a high cockpit workload situation existed.
Final Report:

Crash of a De Havilland DH.60 Moth off Ettalong Beach

Date & Time: Sep 18, 1941
Type of aircraft:
Registration:
VH-UAH
Survivors:
Yes
Schedule:
Sydney - Ettalong Beach
MSN:
245
YOM:
1926
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine airplane departed Sydney-Mascot Airport on a charter service to Ettalong Beach. On approach, it went out of control and crashed into the sea few hundred metres offshore. Both occupants were rescued and the airplane was damaged beyond repair. This was the fifth accident for this airplane since 1926. It was not repaired.

Crash of an Avro 652 Anson I in Glenbrook: 5 killed

Date & Time: Jan 28, 1941
Type of aircraft:
Operator:
Registration:
A4-5
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Parkes – Sydney
MSN:
971
YOM:
1936
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The twin engine airplane departed Parkes on an ambulance flight to Sydney-Mascot Airport, carrying one patient, one doctor and three crew members. While overflying Glenbrook at low height, the twin engine aircraft went out of control and crashed at the intersection of two streets, downtown Glenbrook. While no one on the ground was injured, all five occupants were killed.
Crew:
P/O J. I. Newman, pilot,
F/O Henry Theodore Skillman, copilot,
AC1 C. R. Tysoc, wireless operator.
Passengers:
S/L James Manning Rainbow, medical officer,
P/O Bailey Middlebrook Sawyer, patient.
Probable cause:
According to witnesses, it appears the aircraft went out of control following a partial loss of the left wing, maybe due to a structural failure.

Ground fire of a De Havilland DH.89 Dragon Rapide in Sydney

Date & Time: May 12, 1937
Operator:
Registration:
VH-UVS
Flight Phase:
Survivors:
Yes
Schedule:
Sydney – Brisbane
MSN:
6265
YOM:
1934
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
All seven occupants (five passengers and both crew members) were on board and ready for departure on a flight to Brisbane. When the pilot started the engines, one of them exploded and the fire quickly spread to the rest of the structure. All seven occupants were able to evacuate and four were injured, among them the captain. The aircraft was totally destroyed by fire.
Probable cause:
Engine fire at start up.