Crash of a Rockwell Aero Commander 500S off Horn Island: 1 killed

Date & Time: Feb 24, 2011 at 0800 LT
Operator:
Registration:
VH-WZU
Flight Type:
Survivors:
No
Schedule:
Cairns - Horn Island
MSN:
3060
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:
4154
Captain / Total hours on type:
209.00
Aircraft flight hours:
17545
Circumstances:
At 0445 Eastern Standard Time on 24 February 2011, the pilot of an Aero Commander 500S, registered VH-WZU, commenced a freight charter flight from Cairns to Horn Island, Queensland under the instrument flight rules. The aircraft arrived in the Horn Island area at about 0720 and the pilot advised air traffic control that he intended holding east of the island due to low cloud and rain. At about 0750 he advised pilots in the area that he was north of Horn Island and was intending to commence a visual approach. When the aircraft did not arrive a search was commenced but the pilot and aircraft were not found. On about 10 October 2011, the wreckage was located on the seabed about 26 km north-north-west of Horn Island.
Probable cause:
The ATSB found that the aircraft had not broken up in flight and that it impacted the water at a relatively low speed and a near wings-level attitude, consistent with it being under control at impact. It is likely that the pilot encountered rain and reduced visibility when manoeuvring to commence a visual approach. However, there was insufficient evidence available to determine why the aircraft impacted the water.
Several aspects of the flight increased risk. The pilot had less than 4 hours sleep during the night before the flight and the operator did not have any procedures or guidance in place to minimize the fatigue risk associated with early starts. In addition, the pilot, who was also the operator’s chief pilot, had either not met the recency requirements or did not have an endorsement to conduct the types of instrument approaches available at Horn Island and several other locations frequently used by the operator.
Final Report:

Crash of a Pacific Aerospace FU-24A-954 Fletcher in Wynella Station: 1 killed

Date & Time: Dec 20, 2010 at 1700 LT
Type of aircraft:
Registration:
VH-FNM
Survivors:
No
Schedule:
Wynella Station - Wynella Station
MSN:
263
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5815
Circumstances:
On 20 December 2010, the owner/pilot of a Pacific Aerospace Corporation FU-24-954 Fletcher aircraft, registered VH-FNM, was conducting aerial spreading of urea fertilizer at Wynella Station; a property 40 km south-south-west of Dirranbandi, Queensland. At about 1650 Eastern Standard Time, the pilot was returning to the landing strip after the completion of an application run. The aircraft impacted the terrain, and the pilot was fatally injured.
Probable cause:
Examination of the accident site indicated that the aircraft’s engine was delivering power at the time of impact. Wreckage examination did not reveal evidence of any defect or mechanical failure that would have contributed to the event. Although the post-mortem report on the pilot noted that he had significant coronary atherosclerosis, there was insufficient information available to determine whether pilot incapacitation was involved in the accident. The investigation did not identify any organisational or systemic issues that might adversely affect the future safety of aviation
operations.
Final Report:

Crash of a Gippsland GA8 Airvan in Lady Barron

Date & Time: Oct 15, 2010 at 1715 LT
Type of aircraft:
Operator:
Registration:
VH-DQP
Survivors:
Yes
Site:
Schedule:
Lady Barron - Bridport
MSN:
GA8-05-075
YOM:
2005
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2590
Captain / Total hours on type:
1355.00
Circumstances:
The pilot was conducting a charter flight from Lady Barron, Flinders Island to Bridport, Tasmania with six passengers on board. The aircraft departed Lady Barron Aerodrome at about 1700 Australian Eastern Daylight-saving Time and entered instrument meteorological conditions (IMC) several minutes afterwards while climbing to the intended cruising altitude of about 1,500 ft. The pilot did not hold a command instrument rating and the aircraft was not equipped for flight in IMC. He attempted to turn the aircraft to return to Lady Barron Aerodrome but became lost, steering instead towards high ground in the Strzelecki National Park in the south-east of Flinders Island. At about 1715, the aircraft exited cloud in the Strzelecki National Park, very close to the ground. The pilot turned to the left, entering a small valley in which he could neither turn the aircraft nor out climb the terrain. He elected to slow the aircraft to its stalling speed for a forced landing and, moments later, it impacted the tree tops and then the ground. The first passenger to exit the aircraft used the aircraft fire extinguisher to put out a small fire that had begun beneath the engine. The
other passengers and the pilot then exited the aircraft safely. One passenger was slightly injured during the impact; the pilot and other passengers were uninjured. During the night, all of the occupants of the aircraft were rescued by helicopter and taken to the hospital in Whitemark, Flinders Island.
Probable cause:
Contributing safety factors:
• The weather was marginal for flight under the visual flight rules, with broken cloud forecast down to 500 ft above mean sea level in the area.
• The pilot, who did not hold a command instrument rating, entered instrument meteorological conditions because he was adhering to an un-written operator rule not to fly below 1,000 ft above ground level.
• The pilot became lost in cloud and flew the aircraft towards the Mt Strzelecki Range, exiting the cloud in very close proximity to the terrain.
• The aircraft exited the cloud in a small valley, within which the pilot could neither turn round nor out-climb the terrain.
Other key findings:
• The aircraft exited cloud before impacting terrain and with sufficient time for the pilot to execute a forced landing.
• The design of the aircraft’s seats, and the provision to passengers in the GA-8 Airvan of three-point automotive-type restraint harnesses with inertia reel shoulder straps contributed to the passengers’ survival, almost without injury.
Final Report:

Crash of a Gippsland GA-8 Airvan in Orange

Date & Time: Jul 6, 2010 at 1745 LT
Type of aircraft:
Operator:
Registration:
VH-YBH
Flight Type:
Survivors:
Yes
Schedule:
Parkes - Orange
MSN:
GA8-08-131
YOM:
2008
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Pilot was performing a cargo flight from Parkes to Orange, New South Wales. On final approach, single engine aircraft was too low and hit the roof of a metal hangar located near the runway threshold. Aircraft stalled, hit the runway surface and lost its nose gear. It veered off runway and eventually collided with a metal hangar under construction. While the pilot was injured, the aircraft was destroyed.
Probable cause:
Wrong approach configuration on part of the pilot.

Crash of a Piper PA-31 Navajo Chieftain in Bankstown: 2 killed

Date & Time: Jun 15, 2010 at 0805 LT
Operator:
Registration:
VH-PGW
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Bankstown - Brisbane - Albury
MSN:
31-8414036
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2435
Captain / Total hours on type:
779.00
Aircraft flight hours:
6266
Circumstances:
Twin engine aircraft, with a pilot and a flight nurse on board, was being operated by Skymaster Air Services under the instrument flight rules (IFR) on a flight from Bankstown Airport, New South Wales (NSW) to Archerfield Airport, Queensland. The aircraft was being positioned to Archerfield for a medical patient transfer flight from Archerfield to Albury, NSW. The aircraft departed Bankstown at 0740 Eastern Standard Time. At 0752, the pilot reported to air traffic control (ATC) that he was turning the aircraft around as he was having ‘a few problems. At about 0806, the aircraft collided with a powerline support pole located on the eastern side of the intersection of Sackville Street and Canley Vale Road, Canley Vale, NSW. The pilot and flight nurse sustained fatal injuries and the aircraft was destroyed by impact damage and a post-impact fire.
Probable cause:
• While the aircraft was climbing to 9,000 ft the right engine sustained a power problem and the pilot subsequently shut down that engine.
• Following the shutdown of the right engine, the aircraft's descent profile was not optimized for one engine inoperative flight.
• The pilot conducted a descent towards Bankstown Airport that was consistent with a normal arrival profile without first verifying that the aircraft was capable of achieving adequate performance with one engine inoperative.
• Following the engine problem, the aircraft's flightpath and the pilot’s communication with air traffic control indicated that the pilot's situation awareness was less than optimal.
• The aircraft collided with a powerline support pole on the eastern side of the intersection of Sackville Street and Canley Vale Road, Canley Vale, about 6 km north-west of Bankstown Airport.
Final Report:

Crash of an Embraer EMB-120ER Brasília in Darwin: 2 killed

Date & Time: Mar 22, 2010 at 1009 LT
Type of aircraft:
Operator:
Registration:
VH-ANB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Darwin - Darwin
MSN:
120-116
YOM:
1988
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8217
Captain / Total hours on type:
3749.00
Copilot / Total flying hours:
5664
Copilot / Total hours on type:
3085
Aircraft flight hours:
32799
Aircraft flight cycles:
33700
Circumstances:
Aircraft crashed moments after takeoff from runway 29 at Darwin Airport, Northern Territory, fatally injuring both pilots. The flight was for the purpose of revalidating the command instrument rating of the pilot under check and was under the command of a training and checking captain, who occupied the copilot’s seat. The takeoff included a simulated engine failure. Data from the aircraft’s flight recorders was used to establish the circumstances leading to the accident and showed that the pilot in command (PIC) retarded the left power lever to flight idle to simulate an engine failure. That introduced a simulated failure of the left engine and propeller autofeathering system. The increased drag from the ‘windmilling’ propeller increased the control forces required to maintain the aircraft’s flightpath. The pilot under check allowed the speed to decrease and the aircraft to bank toward the inoperative engine. Additionally, he increased power on the right engine, and engaged the yaw damper in an attempt to stabilize the aircraft’s flight. Those actions increased his workload and made control of the aircraft more difficult. The PIC did not restore power to the left engine to discontinue the manoeuvre. The few seconds available before the aircraft became uncontrollable were insufficient to allow ‘trouble shooting’ and deliberation before resolving the situation.
Probable cause:
• The pilot in command initiated a simulated left engine failure just after becoming airborne and at a speed that did not allow adequate margin for error.
• The pilot in command simulated a failure of the left engine by selecting flight idle instead of zero thrust, thereby simulating a simultaneous failure of the left engine and its propeller autofeather system, instead of a failure of the engine alone.
• The pilot under check operated the aircraft at a speed and attitude (bank angle) that when uncorrected, resulted in a loss of control.
• The pilot under check increased his workload by increasing torque on the right engine and selecting the yaw damper.
• The pilot in command probably became preoccupied and did not abandon the simulated engine failure after the heading and speed tolerance for the manoeuvre were exceeded and before control of the aircraft was lost.
Final Report:

Crash of a Cessna 208 Caravan in Beagle Bay

Date & Time: Jan 14, 2010 at 0645 LT
Type of aircraft:
Operator:
Registration:
VH-NTQ
Flight Type:
Survivors:
Yes
Schedule:
Broome - Koolan Island
MSN:
208-0635
YOM:
1997
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Aircraft was en-route from Broome to Koolan Island, Western Australia (WA) at an altitude of about 9,500 ft, when the pilot noticed a drop in the engine torque indication, with a corresponding drop in the engine oil pressure indication. The pilot diverted to the nearest airstrip, which was Beagle Bay, WA. The pilot shut the engine down when the low oil pressure warning light illuminated and conducted a landing at Beagle Bay airstrip. The aircraft overran the airstrip, coming to rest upside down after impacting a mound of dirt. The aircraft was seriously damaged. The pilot, who was the only occupant, sustained minor injuries.
Probable cause:
From the evidence available it was evident that the engine had a substantial in-flight oil leak, which necessitated the in-flight shut down of the engine and a diversion to the nearest available airstrip. The accident damage to the engine in the area of the apparent oil leak precluded a conclusive finding as to the source of the leak. Although the detailed examination of the oil tube attachment lug fracture surfaces was inconclusive, the oil tube remained the most likely source of the oil leak. Evidence from other oil tube failures indicated that significant vibratory loading can cause the oil tube attachment lugs to fracture in the manner observed in the oil tube fitted to VH-NTQ. There was no evidence that the transfer tube was subjected to vibration from a compressor turbine or power turbine blade failure or of an incorrectly fitted engine mount. There was also no evidence of a pre-accident defect that would have caused a reduction in actual engine torque.
Final Report:

Crash of an IAI-1124 Westwind in Norfolk Island

Date & Time: Nov 18, 2009 at 2156 LT
Type of aircraft:
Operator:
Registration:
VH-NGA
Flight Type:
Survivors:
Yes
Schedule:
Apia - Norfolk - Melbourne
MSN:
387
YOM:
1983
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3596
Captain / Total hours on type:
923.00
Copilot / Total flying hours:
1954
Copilot / Total hours on type:
649
Aircraft flight hours:
21528
Aircraft flight cycles:
11867
Circumstances:
On 18 November 2009, the flight crew of an Israel Aircraft Industries Westwind 1124A aircraft, registered VH-NGA, was attempting a night approach and landing at Norfolk Island on an aeromedical flight from Apia, Samoa. On board were the pilot in command and copilot, and a doctor, nurse, patient and one passenger. On arrival, weather conditions prevented the crew from seeing the runway or its visual aids and therefore from landing. The pilot in command elected to ditch the aircraft in the sea before the aircraft’s fuel was exhausted. The aircraft broke in two after ditching. All the occupants escaped from the aircraft and were rescued by boat.
Probable cause:
The pilot in command did not plan the flight in accordance with the existing regulatory and operator requirements, precluding a full understanding and management of the potential hazards affecting the flight. The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination. The flight crew’s delayed awareness of the deteriorating weather at Norfolk Island combined with incomplete flight planning to influence the decision to continue to the island, rather than divert to a suitable alternate.

Final Report:

Crash of a Piper PA-31 Navajo Chieftain in Darwin

Date & Time: Feb 6, 2009 at 0840 LT
Operator:
Registration:
VH-TFX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Darwin-Maningrida
MSN:
31-8152143
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:

Shortly after take off, engine problem forced the pilot to return to the airport but the aircraft crashed 200 meters off shore. All occupants were rescued but the aircraft was damaged beyond repair.

Crash of a Piper PA-31 Navajo Chieftain in Bathurst: 4 killed

Date & Time: Nov 7, 2008 at 2024 LT
Operator:
Registration:
VH-OPC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Melbourne-Bathurst-Port Macquarie
MSN:
31-7952082
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2061
Aircraft flight hours:
11000
Circumstances:

The twin engine aircraft crashed shortly after take off from Bathurst airport, outbound for Port Macquarie. The aircraft hit trees and crashed in an open field located 3 km from airport. All 4 occupants were killed. According ATSB, investigation was unable to establish why the aircraft collided with terrain; however, pilot spatial disorientation or pilot incapacitation could not be discounted.