Region

Crash of a Cessna 208B Grand Caravan on Lizard Island

Date & Time: Jan 8, 2024 at 0700 LT
Type of aircraft:
Registration:
VH-NWJ
Survivors:
Yes
Schedule:
Lizard Island - Cairns
MSN:
208B-2161
YOM:
2010
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After takeoff from Lizard Island Airport, the crew continued to climb until he reached the altitude of 4,000 feet. Due to an engine malfunction, the crew decided to return to Lizard Island Airport but the airplane overshot and crashed, coming to rest upside down. All 10 occupants were injured and evacuated.

Crash of a Cessna 421C Golden Eagle III off Sunshine Coast

Date & Time: Nov 10, 2023 at 0906 LT
Operator:
Registration:
VH-VPY
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Sunshine Coast - Pago Pago
MSN:
421C-0688
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed Sunshine Coast-Caloundra Airport at 0733LT on a flight to Pago Pago, US Samoa, with two people on board. About 45 minutes into the flight, while cruising at an approximate altitude of 12,000 feet, the pilot inform ATC about an engine failure and elected to return to Sunshine Coast. He made a 180 turn and reduced his altitude. About 45 minutes later, unable to reach his departure airport, the pilot ditched the airplane some 30 nautical miles east of Sunshine Coast. Both occupants found refuge in a dinghy and were quickly rescued. The airplane sank and was lost.

Crash of a Rockwell Gulfstream 695A Jetprop 1000 near Cloncurry: 3 killed

Date & Time: Nov 4, 2023 at 1430 LT
Operator:
Registration:
VH-HPY
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Toowoomba - Mount Isa
MSN:
96051
YOM:
1982
Flight number:
BDOG370
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
In the early afternoon, the twin engine airplane departed Toowoomba Airport on an aerial survey flight under callsign BDOG370 to Mount Isa with three people on board. The purpose of the flight was to conduct a survey mission of the area in case of bushfire. While cruising at an altitude of 28,000 feet, the airplane entered an uncontrolled descent. It reached a rate of descent of 9,600 feet per minute until it crashed in an uninhabited area located approximately 70 km southeast of Cloncurry. All three occupants were killed.

Crash of a Piper PA-31-350 Navajo Chieftain in Hillcrest

Date & Time: Apr 7, 2023 at 0605 LT
Operator:
Registration:
VH-HJE
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Bankstown – Brisbane
MSN:
31-7852074
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed Bankstown Airport on a cargo flight to Brisbane, carrying one pilot and medical stuffs. While descending to Brisbane-Archerfield Airport, the pilot encountered technical problems with the engines that lost power and attempted an emergency landing. The airplane impacted trees and crashed in a grassy area located along a railway road in Hillcrest, some 10 km south of Archerfield Airport. The pilot escaped with minor injuries.

Crash of a Boeing 737-3H4 in the Fitzgerald River National Park

Date & Time: Feb 6, 2023 at 1613 LT
Type of aircraft:
Operator:
Registration:
N619SW
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Busselton - Busselton
MSN:
28035/2762
YOM:
1995
Flight number:
Bomber 139
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The airplane departed Busselton-Margaret River Airport at 1532LT on a fire fighting mission under callsign Bomber 139 (B139). Following a flight at FL290, the crew descended to the Fitzgerald River National Park and completed a circuit over the area. After the retardants were dropped, the crew elected to gain height when the airplane crashed in a wooded area, bursting into flames. Both pilots evacuated with minor injuries and the airplane was destroyed by fire.

Crash of a Britten-Norman BN-2A-21 Islander on Moa Island

Date & Time: Oct 3, 2022 at 1340 LT
Type of aircraft:
Operator:
Registration:
VH-WQA
Flight Phase:
Survivors:
Yes
Schedule:
Saibai Island - Horn Island
MSN:
494
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The airplane was completing a routine school charter flight from Saibai Island to Horn Island. En route, the pilot encountered engine troubles and was forced to shut down one engine. He reduced his altitude and attempted an emergency landing on Moa Island when the airplane impacted trees and crashed in a wooded area. The tail section separated upon impact and the aircraft was damaged beyond repair. Fortunately, all seven occupants evacuated safely.

Crash of a Cessna 404 Titan in Lockhart River: 5 killed

Date & Time: Mar 11, 2020 at 0919 LT
Type of aircraft:
Registration:
VH-OZO
Survivors:
No
Schedule:
Cairns – Lockhart River
MSN:
404-0653
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
3220
Captain / Total hours on type:
399.00
Circumstances:
On 11 March 2020, a Cessna 404 aircraft, registered VH-OZO, was being operated by Air Connect Australia to conduct a passenger charter flight from Cairns to Lockhart River, Queensland. On board were the pilot and 4 passengers, and the flight was being conducted under the instrument flight rules (IFR). Consistent with the forecast, there were areas of cloud and rain that significantly reduced visibility at Lockhart River Airport. On descent, the pilot obtained the latest weather information from the airport’s automated weather information system (AWIS) and soon after commenced an area navigation (RNAV) global satellite system (GNSS) instrument approach to runway 30. The pilot conducted the first approach consistent with the recommended (3°) constant descent profile, and the aircraft kept descending through the minimum descent altitude (MDA) of 730 ft and passed the missed approach point (MAPt). At about 400 ft, the pilot commenced a missed approach. After conducting the missed approach, the pilot immediately commenced a second RNAV GNSS approach to runway 30. During this approach, the pilot commenced descent from 3,500 ft about 2.7 NM prior to the intermediate fix (or 12.7 NM prior to the MAPt). The descent was flown at about a normal 3° flight path, although about 1,000 ft below the recommended descent profile. While continuing on this descent profile, the aircraft descended below the MDA. It then kept descending until it collided with terrain 6.4 km (3.5 NM) short of the runway. The pilot and 4 passengers were fatally injured, and the aircraft was destroyed.
Probable cause:
The accident was the consequence of a controlled flight into terrain.
The following contributing factors were identified:
• While the pilot was operating in the vicinity of Lockhart River Airport, there were areas of cloud and rain that significantly reduced visibility and increased the risk of controlled flight into terrain.
In particular, the aircraft probably entered areas of significantly reduced visibility during the second approach.
• After an area navigation (RNAV) global satellite system (GNSS) approach to runway 30 and missed approach, the pilot immediately conducted another approach to the same runway that was on a similar gradient to the recommended descent profile but displaced about 1,000 ft below that profile. While continuing on this descent profile, the aircraft descended below a segment minimum safe altitude and the minimum descent altitude, then kept descending until the collision with terrain about 6 km before the runway threshold.
• Although the exact reasons for the aircraft being significantly below the recommended descent profile and the continued descent below the minimum descent altitude could not be determined, it was evident that the pilot did not effectively monitor the aircraft’s altitude and descent rate for an extended period.
• When passing the final approach fix (FAF), the aircraft’s lateral position was at about full-scale deflection on the course deviation indicator (CDI), and it then exceeded full-scale deflection for
an extended period. In accordance with the operator’s stabilized approach procedures, a missed approach should have been conducted if the aircraft exceeded half full-scale deflection at the FAF, however a missed approach was not conducted.
• The pilot was probably experiencing a very high workload during periods of the second approach. In addition to the normal high workload associated with a single pilot hand flying an approach in instrument meteorological conditions, the pilot’s workload was elevated due to conducting an immediate entry into the second approach, conducting the approach in a different manner to their normal method, the need to correct lateral tracking deviations throughout the approach, and higher than appropriate speeds in the final approach segment.
• The aircraft was not fitted with a terrain avoidance and warning system (TAWS). Such a system would have provided visual and aural alerts to the pilot of the approaching terrain for an extended period, reducing the risk of controlled flight into terrain.
• Although the aircraft was fitted with a GPS/navigational system suitable for an area navigation (RNAV) global satellite system (GNSS) approach and other non-precision approaches, it was not fitted with a system that provided vertical guidance information, which would have explicitly indicated that the aircraft was well below the recommended descent profile. Although the operator had specified a flight profile for a straight-in approaches and stabilized approach criteria in its operations manual, and encouraged the use of stabilized approaches, there were limitations with the design of these procedures. In addition, there were limitations with other risk controls for minimizing the risk of controlled flight into terrain (CFIT), including no procedures or guidance for the use of the terrain awareness function on the aircraft’s GNS 430W GPS/navigational units and limited monitoring of the conduct of line operations.

Other factors that increased risk:
• Although an applicable height of 1,000 ft for stabilized approach criteria in instrument meteorological conditions has been widely recommended by organizations such as the International Civil Aviation Organization for over 20 years, the Civil Aviation Safety Authority had not provided formal guidance information to Australian operators regarding the content of stabilized approach criteria. (Safety issue)
• The Australian requirements for installing a terrain avoidance and warning system (TAWS) were less than those of other comparable countries for some types of small aeroplanes conducting air transport operations, and the requirements were not consistent with International Civil Aviation Organization (ICAO) standards and recommended practices. More specifically, although there was a TAWS requirement in Australia for turbine-engine aeroplanes carrying 10 or more passengers under the instrument flight rules:
- There was no requirement for piston-engine aeroplanes to be fitted with a TAWS, even though this was an ICAO standard for such aeroplanes authorized to carry 10 or more passengers, and this standard had been adopted as a requirement in many comparable countries.
- There was no requirement for turbine-engine aeroplanes authorized to carry 6–9 passengers to be fitted with a TAWS, even though this had been an ICAO recommended practice since 2007, and this recommended practice had been adopted as a requirement in many comparable countries. (Safety Issue)

Other findings:
• The forecast weather at Lockhart River for the time of the aircraft’s arrival required the pilot to plan for 60 minutes holding or diversion to an alternate aerodrome. The aircraft had sufficient fuel for that purpose; and the aircraft had sufficient fuel to conduct the flight from Cairns to Lockhart River and return, with additional fuel for holding on both sectors if required.
• There was no evidence of any organizational or commercial pressure to conduct the flight to Lockhart River or to complete the flight once to commenced.
• Based on the available evidence, it is very unlikely that the pilot was incapacitated or impaired during the flight.
• There was no evidence of any aircraft system or mechanical anomalies that would have directly influenced the accident. However, as a consequence of extensive aircraft damage, it was not possible to be conclusive about the aircraft’s serviceability.
• The aircraft was fitted with Garmin GNS 430W GPS/navigational units that could be configured to provide visual (but not aural) terrain alerts. However, it could not be determined whether the
terrain awareness function was selected on during the accident flight.
Final Report:

Crash of a Lockheed EC-130Q Hercules near Peak View: 3 killed

Date & Time: Jan 23, 2020 at 1315 LT
Type of aircraft:
Operator:
Registration:
N134CG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Richmond - Richmond
MSN:
4904
YOM:
1981
Flight number:
Bomber 134
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4010
Captain / Total hours on type:
3010.00
Copilot / Total flying hours:
1744
Copilot / Total hours on type:
1364
Aircraft flight hours:
11888
Circumstances:
At about 1205, while B137 was overhead the Adaminaby fire-ground, and about the same time the SAD logged the birddog rejection, B134 departed Richmond as initial attack. On board were the PIC, the copilot and flight engineer. In response to the draft report, the RFS provided excerpts from the state operations controller (SOC) log. An entry was written in the log by the SOC following the accident. The SOC noted having been advised that the birddog had indicated it was ‘not safe to fly’ and that B137 was not returning to the area until the conditions had eased. However, B134 would continue with the PIC to make the ‘decision of safety of bombing operations’. The RFS advised the ATSB that the SOC had the authority to cancel B134’s tasking, but instead allowed it to proceed, with the intention of gathering additional intelligence to assist in determining whether further aerial operations would proceed. The RFS further reported that this indicated an ongoing intelligence gathering and assessment process by the SOC. At about 1235, while returning to Richmond, the PIC of B137 heard the PIC of B134 on the Canberra approach frequency, and contacted them via their designated operating frequency. At that time, B134 was about 112 km north-east of Adaminaby, en route to the fire-ground. In this conversation, the PIC of B137 informed them of the actual conditions and that they would not be returning to Adaminaby. The PIC of B137 reported that they could not recall the specific details of the call, but that the conversation included that they were ‘getting crazy winds’ and ‘you can go take a look’ ’but I am not going back’. It was also noted that the PIC of B134 had asked several questions. It was reported by the majority of the operator’s pilots that, despite receiving information from another pilot, they would have also continued with the tasking under these circumstances, to assess the conditions themselves. At about 1242, the crew of B134 contacted air traffic control to advise them of the coordinates they would be working at, provide an ‘ops normal’ call time, and confirm there was no reported instrument flight rules aircraft in the area. About 5 minutes later, the Richmond ABM also attempted to contact the crew of B134 to confirm ‘ops normal’, firstly by radio, and then by text to the PIC’s mobile phone, but did not receive a response. The automatic dependent surveillance broadcast (ADS-B) data showed that, after arriving at the Adaminaby fire-ground at about 1251, the crew of B134 completed several circuits at about 2,000 ft AGL. At about 1255, the crew advised the Cooma ARO that it was too smoky and windy to complete a retardant drop at that location. The Cooma ARO then provided the crew with the approximate coordinates of the Good Good fire, about 58 km to the east of Adaminaby. The ARO further indicated that they had no specific requirements, but they could look for targets of opportunity, with the objective of conducting structure and property protection near Peak View. At about 1259, the crew of B134 contacted air traffic control to advise that they had been re-tasked to the Good Good fire-ground, and provided updated coordinates. At about the same time, the RFS ground firefighters at the Good Good fire-ground, near Feeney’s Road in Peak View, contacted the Cooma FCC and requested additional assets for property protection. They were advised that a LAT would be passing overhead in about 10 minutes. The firefighters acknowledged the intention of a LAT retardant drop and advised the Cooma FCC they would wait in open country on Feeney’s Road, clear of any properties targeted for protection. At about 1307, B134 arrived overhead the drop area. The drop area was located to the east of a ridgeline, with the fire on the western side of the ridgeline. The aircraft’s recorded track data (SkyTrac) showed that the crew conducted 3 left circuits, at about 1,500 ft, 500 ft and 1,000 ft AGL respectively, prior to commencing the drop circuit. At about 1312, after conducting about 2 circuits, they advised the Cooma ARO of their intention to complete multiple drops on the eastern side of the Good Good fire, and that they would advise the coordinates after the first delivery. At 1315:15, a partial retardant drop was conducted on a heading of about 190°, at about 190 ft AGL (3,600 ft above mean sea level). During the drop, about 1,200 US gallons (4,500 L) of fire retardant was released over a period of about 2 seconds. A ground speed of 144 kt was recorded at the time of the drop. A witness video taken by ground fire-fighters captured the drop and showed the aircraft immediately after the drop in an initial left turn with a positive rate of climb, before it became obscured by smoke. While being intermittently obscured by smoke, the aircraft climbed to about 330 ft AGL (3,770 ft above mean sea level). At about this time, ATSB analysis of the video showed that the aircraft was rolling from about 18° left angle of bank to about a 6° right angle of bank. Following this, the aircraft descended and about 17 seconds after the completion of the partial retardant drop, it was seen at a very low height above the ground, in a slight left bank. Video analysis and accident site examination showed there was no further (emergency) drop of retardant. Throughout this period, the recorded groundspeed increased slightly to a maximum of 151 kt. Shortly after, there was a significant left roll just prior to ground impact. At about 1315:37, the aircraft collided with terrain and a post-impact fuel-fed fire ensued. The 3 crew were fatally injured and the aircraft was destroyed. A review of the Airservices Australia audio recording of the applicable air traffic control frequency found no distress calls were received by controllers prior to the impact.
Probable cause:
The following contributing factors were identified:
- Hazardous weather conditions were forecast and present at the drop site near Peak View, which included strong gusting winds and mountain wave activity, producing turbulence. These
conditions were likely exacerbated by the fire and local terrain.
- The Rural Fire Service continued the B134 tasking to Adaminaby when they learned that no other aircraft would continue to operate due to the environmental conditions. In addition, they relied on the pilot in command to assess the appropriateness of the tasking to Adaminaby without providing them all the available information to make an informed decision on flight safety.
- The pilot in command of B134 accepted the Adaminaby fire-ground tasking, which was in an area of forecast mountain wave activity and severe turbulence. After assessing the conditions as unsuitable, the crew accepted an alternate tasking to continue to the Good Good (Peak View) fire-ground, which was subject to the same weather conditions. The acceptance of these taskings were consistent with company practices.
- Following the partial retardant drop and left turn, the aircraft was very likely subjected to hazardous environmental conditions including low-level windshear and an increased tailwind component, which degraded the aircraft’s climb performance.
- While at a low height and airspeed, it was likely the aircraft aerodynamically stalled, leading to a collision with terrain.
- Coulson Aviation's safety risk management processes did not adequately manage the risks associated with large air tanker operations. There were no operational risk assessments conducted or a risk register maintained. Further, as safety incident reports submitted were mainly related to maintenance issues, operational risks were less likely to be considered or monitored. Overall, this limited their ability to identify and implement mitigations to manage the risks associated with their aerial firefighting operations. (Safety issue)
- Coulson Aviation did not provide a pre-flight risk assessment for their firefighting large air tanker crews. This would provide predefined criteria to ensure consistent and objective decision-making with accepting or rejecting tasks, including factors relating to crew, environment, aircraft and external pressures. (Safety issue)
- The New South Wales Rural Fire Service had limited large air tanker policies and procedures for aerial supervision requirements and no procedures for deployment without aerial supervision.(Safety issue)
- The New South Wales Rural Fire Service did not have a policy or procedures in place to manage task rejections, nor to communicate this information internally or to other pilots working in the same area of operation. (Safety issue)

Other factors that increased risk:
- The B134 crew were very likely not aware that the 'birddog' pilot had declined the tasking to Adaminaby fire-ground, and the smaller fire-control aircraft had ceased operations in the area, due to the hazardous environmental conditions
- In the limited time available, the remainder of the fire-retardant load was not jettisoned prior to the aircraft stalling.
- Coulson Aviation did not include a windshear recovery procedure or scenario in their C-130 Airplane Flight Manual and annual simulator training respectively, to ensure that crews consistently and correctly responded to a windshear encounter with minimal delay. (Safety issue)
- Coulson Aviation fleet of C-130 aircraft were not fitted with a windshear detection system, which increased the risk of a windshear encounter and/or delayed response to a windshear encounter during low level operations. (Safety issue)
- The New South Wales Rural Fire Service procedures allowed operators to determine when pilots were initial attack capable. However, they intended for the pilot in command to be certified by the United States Department of Agriculture Forest Service certification process. (Safety issue)

Other findings:
- The aircraft's cockpit voice recorder did not record the accident flight, which resulted in a valuable source of safety information not being available. This limited the extent to which potential factors contributing to the accident could be identified.
Final Report:

Crash of an Angel Aircraft Corporation Model 44 Angel in Mareeba: 2 killed

Date & Time: Dec 14, 2019 at 1115 LT
Registration:
VH-IAZ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mareeba - Mareeba
MSN:
004
YOM:
2008
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
20000
Captain / Total hours on type:
300.00
Copilot / Total flying hours:
5029
Copilot / Total hours on type:
0
Aircraft flight hours:
1803
Circumstances:
On 14 December 2019, at 1046 Eastern Standard Time, an Angel Aircraft Corporation Model 44 aircraft, registered VH-IAZ, commenced taxiing at Mareeba Airport, Queensland. On board the aircraft were two pilots. The pilot in the left seat (‘the pilot’) owned the aircraft and was undertaking a flight review, which was being conducted by the Grade 1 flight instructor in the right seat (‘the instructor’). The planned flight was to operate in the local area, as a private flight and under visual flight rules. As the aircraft taxied towards the runway intersection, the pilot broadcast on the common traffic advisory frequency (CTAF) that VH-IAZ was taxiing for runway 28. The pilot made another broadcast when entering and backtracking the runway, then at 1058, broadcast that the aircraft had commenced the take-off roll. Witnesses who heard the aircraft during the take-off reported that it sounded like one of the engines was hesitating and misfiring. An aircraft maintainer who observed the aircraft take off, reported seeing black sooty smoke trailing from the right engine. The maintainer then watched the aircraft climb slowly and turn right towards the north. Another witness who heard the aircraft in flight soon afterwards, reported that it sounded normal for that aircraft, which had a distinctive sound because the engines’ exhaust gases pass through the propellers. Once airborne, the pilot broadcast that they were ‘making a low-level right-hand turn and then climbing up to not above 4,500 [feet] for the south-west training area.’ About 2 minutes later, the instructor broadcast that they were just to the west of the airfield in the training area at 2,500 ft and on climb to 4,000 ft, and communicated with a helicopter pilot operating in the area. After 8 minutes in the training area, the pilot broadcast that they were inbound to the aerodrome. At 1112, the aircraft’s final transmission was broadcast by the pilot, advising that they were joining the crosswind circuit leg for runway 28. Witnesses then saw the aircraft touch down on the runway and continue to take off again, consistent with a ‘touch-and-go’ manoeuvre, and heard one engine ‘splutter’ as the aircraft climbed to an estimated 100–150 ft above ground level. At about 1115, the aircraft was observed overhead a banana plantation beyond the end of the runway, banked to the right in a descending turn, before it suddenly rolled right. Witnesses observed the right wing drop to near vertical and the aircraft impacted terrain in a cornfield. Both pilots were fatally injured and the aircraft was destroyed.
Probable cause:
Contributing factors:
• The flight instructor very likely conducted a simulated engine failure after take-off in environmental conditions and a configuration in which the aircraft was unable to maintain altitude with one engine inoperative.
• Having not acted quickly to restore power to the simulated inoperative engine, the pilots did not reduce power and land ahead (in accordance with the Airplane Flight Manual procedure) before the combination of low airspeed and bank angle resulted in a loss of directional control at a height too low to recover.
• The instructor had very limited experience with the aircraft type, and with limited preparation for the flight, was likely unaware of the landing gear and flap retraction time and the extent of their influence on performance with one engine inoperative.

Other factors that increased risk:
• The pilot had not flown for 3 years prior to the accident flight, which likely resulted in a decay in skills at managing tasks such as an engine failure after take-off and in decision-making ability. The absence of flying practice before the flight review probably affected the pilot’s ability to manage the asymmetric low-level flight.
• The aircraft had not been flown for more than 2 years and had not been stored in accordance with the airframe and engine manufacturers’ recommendations. This very likely resulted in some of the right engine cylinders running with excessive fuel to air ratio for complete combustion and may also have reduced the expected service life of both engines’ components.
• The right-side altimeter was probably set to an incorrect barometric pressure, resulting in it over-reading the aircraft’s altitude by about 90 ft.
Final Report:

Crash of a Britten-Norman BN-2A-20 Islander in West Portal: 1 killed

Date & Time: Dec 8, 2018 at 0828 LT
Type of aircraft:
Operator:
Registration:
VH-OBL
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Cambridge – Bathurst Harbour
MSN:
2035
YOM:
1986
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
540
Captain / Total hours on type:
80.00
Aircraft flight hours:
12428
Circumstances:
On 8 December 2018, the pilot of a Pilatus Britten-Norman BN2A-20 Islander, registered VH-OBL and operated by Airlines of Tasmania, was conducting a positioning flight under the visual flight rules from Cambridge Airport to the Bathurst Harbour aeroplane landing area (ALA), Tasmania. The aircraft departed Cambridge at about 0748 Eastern Daylight-saving Time and was scheduled to arrive at Bathurst Harbour about 0830 to pick up five passengers for the return flight. The passengers were part of a conservation project that flew to south-west Tasmania regularly, and it was the pilot’s only flight for that day. Automatic dependent surveillance broadcast (ADS-B) position and altitude data (refer to the section titled Recorded information) showed the aircraft tracked to the south-west towards Bathurst Harbour (Figure 1). At about 0816, the aircraft approached a gap in the Arthur Range known as ‘the portals’. The portals are a saddle (lowest area) between the Eastern and Western Arthur Range, and was an optional route that Airlines of Tasmania used between Cambridge and Bathurst Harbour when the cloud base prevented flight over the mountain range. After passing through the portals, the aircraft proceeded to conduct a number of turns below the height of the surrounding highest terrain. The final data point recorded was at about At about 0829, the Australian Maritime Safety Authority received advice that an emergency locator transmitter allocated to VH-OBL had activated. They subsequently advised the Tasmanian Police and the aircraft operator of the activation, and initiated search and rescue efforts. The rescue efforts included two helicopters and a Challenger 604 search and rescue jet aircraft. The Challenger arrived over the emergency locator transmitter signal location at around 0925, however, due to cloud cover the crew were unable to visually identify the precise location of VH-OBL. A police rescue helicopter arrived at the search area at about 1030. The pilot of that helicopter reported observing cloud covering the eastern side of the Western Arthur Range, and described a wall of cloud with its base sitting on the bottom of the west portal. Multiple attempts were made throughout the day to locate the accident site, however, due to low-level cloud, and fluctuating weather conditions, the search and rescue operation was unable to confirm visual location of the aircraft until about 1900. The aircraft wreckage was found in mountainous terrain of the Western Arthur Range in the Southwest National Park (Figure 2) . The search and rescue crew assessed that the accident was unlikely to have been survivable. The helicopter crew considered winching personnel to the site, however, due to a number of risks, including potential for cloud reforming, the time of day and lighting, and other hazards associated with the mountainous location, the helicopter departed the area. The aircraft wreckage was accessed the following day, when it was confirmed that the pilot was fatally injured.
Probable cause:
From the evidence available, the following findings are made with respect to the controlled flight into terrain involving Pilatus Britten-Norman BN2A, VH-OBL, 101 km west-south-west of Hobart, Tasmania, on 8 December 2018.
Contributing factors:
• The pilot continued descending over the Arthur Range saddle to a lower altitude than previous flights, likely due to marginal weather. This limited the options for exiting the valley surrounded
by high terrain.
• While using a route through the Arthur Range due to low cloud conditions, the pilot likely encountered reduced visual cues in close proximity to the ground, as per the forecast conditions. This led to controlled flight into terrain while attempting to exit the range.
Final Report: