Crash of a Rockwell Shrike Commander 500S off Hobart

Date & Time: Apr 27, 1981 at 1814 LT
Operator:
Registration:
VH-EXQ
Survivors:
Yes
Schedule:
Melbourne – Hobart
MSN:
500-1831-28
YOM:
1968
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1925
Captain / Total hours on type:
77.00
Circumstances:
Due to industrial action, normal domestic airline services had been suspended. The pilot hired the aircraft to convey persons stranded by the strike between Hobart and Melbourne. He submitted a flight plan for the proposed return flight to Melbourne that nominated operations under the Instrument Flight Rules, although he did not hold an appropriate Instrument Rating. The flight to Melbourne was completed without known incident. After refuelling the aircraft and engaging five passengers, the return flight was commenced. A fare was paid by each passenger although the pilot did not hold either a Charter Licence or an appropriate pilot licence. There was considerable cloud in the vicinity of Hobart Airport which, at 1800 hours, was recorded as one okta stratus, base 800 feet; five oktas stratocumulus, base 3000 feet; five oktas altocumulus, base 11,000 feet. The surface wind was a light westerly, and the runway in use was Runway 30. There were rain showers in the area and the runway was wet. The end of daylight was at approximately 1748 hours. When the pilot of VH-EXQ contacted Hobart Tower at approximately 1800 hours, he reported on descent to 7000 feet and 50km from the airport. As the aircraft proceeded, the Aerodrome Controller cleared it for further descent in stages, to provide vertical separation from a preceding aircraft. The only Instrument Landing System (ILS) approach at Hobart Airport was aligned with Runway 12 and the tailwind for a landing in that direction was only two or three knots. In order to expedite their arrivals, the Aerodrome Controller offered the pilot s of both approaching aircraft the option of a straight-in ILS approach to Runway 12 instead of a circling approach to the into-wind Runway 30. Both pilots accepted. At 1803 hours, the preceding aircraft was cleared for an ILS approach. The pilot of VH-EXQ was then advised to expect the same clearance but, to ensure continued separation from the other aircraft, was instructed to make one circuit of the holding pattern at Tea Tree Locator, a navigational radio aid west of the airport. The pilot misunderstood this instruction and, on reaching Tea Tree at about 1805 hours, he continued towards the airport. At 1807 hours, the Aerodrome Controller cleared VH-EXQ for an ILS approach. The pilot acknowledged this instruction in the normal manner and did not advise that he had already commenced the approach. In descending towards the airport the pilot had maintained a high airspeed of nearly 200 knots. From overhead Tea Tree he could see the lights of the preceding aircraft and endeavoured to reduce his speed so as to maintain separation. As a result, the aircraft was still very high as it approached the runway. This was noted by the Aerodrome Controller and, at 1810 hours, he asked the pilot whether he would be able to land on Runway 12 or would prefer to make an approach for Runway 30. The pilot chose the latter and was cleared to a right base leg for Runway 30. The approach to Runway 12 was abandoned and the aircraft turned left onto a close right downwind leg for Runway 30. The landing gear, which had been extended, and the flaps, which had been set at 1/4 down, were not moved from these positions. The pilot reported that at some stage of the approach to Runway 30 he moved the throttles forward to increase power and maintain height. In response the aircraft yawed slightly to the right. Both propeller levers were then pushed fully forward, both throttles were fully opened and the mixture controls were checked in the full-rich position. The aircraft again swung to the right. Identifying this as evidence that the right engine had failed, and after checking from the tachometer that the right propeller was windmilling at about 1500 RPM, the pilot feathered the right propeller and selected the landing gear and flaps up. He believed that he carried out the feathering action at a height of about 300 feet and an airspeed of about 100 knots. At this time the aircraft was heading southwest, towards Single Hill (elevation 680 feet) on the shore of Frederick Henry Bay. The pilot reported that the aircraft would not maintain height or airspeed and he therefore turned left to avoid the hill. The wings were then held level until the aircraft touched down in the bay. After the aircraft turned right at a close base leg position, but then straightened on a southwesterly heading instead of continuing the turn onto final approach, the Aerodrome Controller asked the pilot to confirm that he was tracking for Runway 30. This transmission was not answered and the Aerodrome Controller again called the aircraft. The pilot then reported that he was having trouble with the right engine and he was going to feather. This transmission was made as the aircraft was approaching Single Hill, just before it turned left and descended from view. There were no further transmissions from the aircraft despite a number of calls by the Aerodrome Controller. The Distress Phase of Search and Rescue (SAR) procedures was declared at 1815 hours. The appropriate emergency services were alerted including a helicopter that was on standby for SAR operations. All six occupants were rescued while the aircraft sank and was lost.
Probable cause:
The probable cause of the accident was that, following an apparent loss of power by the right engine, the pilot did not operate the aircraft in the configuration and at the airspeed necessary for safe single-engine flight. The pilot's responses may have been Influenced by operating under Instrument Flight Rules conditions, for which he was not qualified. The cause of the reported loss of power by the right engine was not determined. The following defects were discovered:
- General mechanical wear in left engine,
- Left engine fuel injector system outside manufacturer's specifications,
- Slight timing fault in one magneto on right engine.
Final Report:

Crash of a Swearingen SA226TC Metro II in Emerald

Date & Time: Apr 2, 1981
Type of aircraft:
Operator:
Registration:
VH-BPL
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
TC-272
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
At liftoff, the pilot lost control of the airplane that crashed on runway. The pilot, sole on board, was injured and the aircraft was damaged beyond repair.

Crash of a Piper PA-31-350 Navajo Chieftain in Portland: 1 killed

Date & Time: Jan 26, 1981 at 1538 LT
Registration:
VH-POC
Flight Phase:
Survivors:
Yes
Schedule:
Portland - Melbourne
MSN:
31-7952087
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
815
Captain / Total hours on type:
83.00
Circumstances:
The operator had undertaken to carry out a ship's crew exchange programme that consisted of transporting 16 persons and their baggage from Portland to Essendon and the same number back to Portland. Similar programmes had been carried out previously and it was known that the passengers usually carried considerable baggage. However, only two Piper PA-31-350 aircraft, VH-POC and VH-RNH, were assigned to the task. Prior to departure Essendon, both pilots attended the Briefing Office and prepared flight plans, intended to operate under the Instrument Flight Rules and the pilots calculated it would be necessary to load 208 minutes fuel for the first return flight to Portland. This included an additional 30 minutes fuel for holding, as was required because of forecast thunderstorm activity, with associated reduced visibility in rain, in the Essendon area. Both pilots elected to have their aircraft refuelled to capacity which, they indicated on their flight plans, would give them a total of 280 minutes endurance; 72 minutes more than required. The aircraft proceeded to Portland without known incident, arriving at about 14:00 hours. After a break for refreshments, the pilots returned to their aircraft at about 1500 hours and carried out pre-flight checks. The passengers arrived at the aerodrome in a number of vehicles. Initially the pilots began to weigh the baggage and record the weights on a manifest. The passengers were in a light-hearted mood, however, and with an atmosphere of some confusion, not all of the baggage was weighed, the manifest was not completed and no individual weights were marked on the bags.The baggage was then transported by trolleys to the aircraft and shared between them without consideration of weight. The baggage in the rear baggage area of the cabin of VH-POC was not restrained to prevent movement. The pilots decided that, by inspection, the average baggage weight per passenger was 20 kg. The accepted standard weight of 77 kg per adult passenger was also assumed. Each pilot then completed a load sheet for his aircraft, on the basis of carrying eight passengers. The sheet for VH-POC indicated that the aircraft fuel load was 290 kg. The total weight calculated for VH-POC was 3,080 kg. This was less than the maximum allowable all-up-weight of 3,178 kg. However, an incorrect aircraft operating weight had been used and an arithmetical error had occurred in the calculation. Correcting for these, the aircraft weight should have been recorded as 3,256 kg. When ready to embark, the passengers were only directed towards the two aircraft. No effort was made to split the party into two even groups and in the event, nine passengers boarded VH-POC. On boarding VH-POC, the pilot did not correct the passenger imbalance. He started both engines and proceeded to taxi for a take-off on Runway 22. Pre-take-off checks were carried out as the aircraft taxied. The weather conditions at the time were fine; visibility 15 km, temperature 22° Celsius, sea level barometric pressure 1007 millibars and surface wind from 210° to 220° magnetic, gusting from 25 to 35 knots. In such wind conditions, and because of the location near a coastal headland, there was significant turbulence present. The pilot of VH-POC had operated into Portland on numerous prior occasions and had experienced this common situation previously. The take-off run was commenced and the pilot reported that full power was obtained from both engines. He stated that at 95 kts the aircraft was rotated and, when a positive rate of climb had been established, the landing gear was retracted. Then, at a height of 60 to 70 feet, just after he had reduced power to the climb setting, the left engine suddenly lost power. Ground witnesses who observed the take-off reported that the aircraft appeared slow to accelerate. Once airborne, it maintained a low climb profile and, at one stage, slewed to the right. Irregular engine noise was heard but it was not identified to a particular engine. The pilot reported that he confirmed a left engine failure by closing the left throttle. On fully re-opening the throttle, however, he noted a slight power response and hence he elected not to shut down the engine and feather the left propeller. Several of the passengers were aware of an abnormal situation but none was aware of the nature of the problem nor could confirm which engine was malfunctioning. They reported that the landing gear audio warning was sounding throughout most of the flight, which indicated a throttle was at or near the closed position. The pilot reported that the aircraft began to lose height and, as a forced landing was imminent, he turned to the right to avoid the sea. Control had been difficult in the gusty conditions but he had managed to reduce speed, lower the landing gear and guide the aircraft to a landing in a reasonably suitable area. The aircraft touched down on undulating-, sandy scrub-covered terrain. The landing gear and engines were torn out and the aircraft came to rest after travelling only some 26 metres. The fuselage broke open near the rear door during the ground slide. Some passengers were able to evacuate the cabin without assistance and they rendered help to the pilot and other passengers. A small fire, which had ignited in the vicinity of the left engine as the aircraft came to rest, then suddenly spread and engulfed the fuselage before the final passenger could be extricated. Subsequent examination of the wreckage was hampered by the extensive fire damage. No pre-existing fault was found in those components that were recovered. An inspection of the left propeller found that it had been feathered at ground impact. It was not possible to establish precisely the aircraft's weight and centre of gravity at the time of the accident as the contents of the nose and engine nacelles baggage compartments were destroyed. The available evidence, however, indicated that the aircraft weighed at least 3400 kg and its centre of gravity was probably beyond the aft limit. Piper PA31-350 performance data indicated that, for a new aircraft, the maximum attainable single-engine rate of climb at the limit weight of 3,178 kg was 220 feet per minute. At a weight of 3,400 kg this would be reduced by about 40 percent to 134 feet per minute. At the higher weight, detracting factors such as aircraft age, turbulence and less than optimum airspeed would have precluded the aircraft from achieving a positive rate of climb. The pilot was briefly interviewed in hospital on 27.1.81. At that time he also submitted a written notification of the accident. Subsequently, he has declined, through industrial counsel, to either attend for an interview under procedures of the Air Safety Investigation Branch or to supply answers to written questions. Hence it has not been possible to fully resolve a number of safety aspects of the accident, such as aircraft loading, the nature of the power loss and subsequent aircraft handling considerations.
Probable cause:
The probable cause of the accident was that the aircraft experienced a loss of power from one engine under conditions which precluded a safe continuation of flight. The two most significant conditions were aircraft overloading and turbulence. The nature and cause of the power loss have not been determined.
Final Report:

Crash of a Fletcher FU-24 in Yass

Date & Time: Dec 31, 1980
Type of aircraft:
Operator:
Registration:
VH-EOA
Flight Phase:
Survivors:
Yes
MSN:
43
YOM:
1957
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances in Yass while engaged in a crop spraying mission. The pilot, sole on board, was injured.

Crash of a Partenavia P.68B in Bankstown

Date & Time: Dec 23, 1980
Type of aircraft:
Operator:
Registration:
VH-IYO
Flight Phase:
Flight Type:
Survivors:
Yes
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Bankstown Airport, while climbing, the twin engine airplane stalled and crashed in a camping lot. The pilot, sole on board, was injured. There were no injuries on ground.

Crash of a Britten-Norman BN-2A Trislander Mk.III-2 near Tumut: 2 killed

Date & Time: Dec 16, 1980
Type of aircraft:
Registration:
VH-EGU
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Bankstown - Melbourne
MSN:
1030
YOM:
1976
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
While flying over the Snowy Mountains on a cargo flight from Bankstown to Melbourne, the pilot reported icing conditions. Shortly later, the three engine airplane went out of control and crashed in a wooded area. The aircraft was destroyed and both occupants were killed. It was later reported that a cold front was coming across the area with low temperatures and icing conditions.
Probable cause:
It is believed that the loss of control was the consequence of an excessive accumulation of ice on airframe as well as on carburetors.

Crash of a Pilatus PC-6/B1-H2 Turbo Porter near Oakey

Date & Time: Nov 28, 1980
Operator:
Registration:
A14-681
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
681
YOM:
1968
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
5840
Circumstances:
While flying at low height, the single engine airplane struck power cables and crashed in an open field, bursting into flames. All occupants escaped with minor injuries while the aircraft was destroyed by fire.

Crash of a Piper PA-61 Aerostar (Ted Smith 601P) in Teutonic Bore: 1 killed

Date & Time: May 28, 1980 at 1137 LT
Operator:
Registration:
VH-KXY
Flight Phase:
Survivors:
Yes
Schedule:
Teutonic Bore – Leonora – Perth
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2810
Captain / Total hours on type:
149.00
Circumstances:
The aircraft was engaged on the return segment of a flight from Perth to Teutonic Bore, with an intended refuelling stop at Leonora. After embarking the two passengers and their baggage, the pilot started the engines and taxied for a take-off into the north, on the 1350 metre long main strip. The weather conditions were fine with a northerly surface wind of about 7 knots. The initial part of the take-off run was apparently normal but, after travelling some 400 metres and at about the point of rotation, one of the passengers noted an engine power surge. The take-off was continued, the aircraft became airborne and shortly afterwards the landing gear was retracted. After the aircraft had slowly climbed straight ahead to an altitude of about 200-300 feet above ground level, the passenger heard a marked change in the engine noise and felt the aircraft decelerating. The extent of the power loss and the absence of any yawing force indicated both engines had lost power simultaneously. Level flight straight ahead was reportedly maintained for an estimated 10 seconds and then the aircraft entered a descending left turn. At about this time the pilot, in response to a query from the passenger, advised that he intended to return to the airstrip but then stated "we're going down", or words to that effect. The terrain in the area was generally firm and flat. It was lightly covered with scrub and there was occasional small trees but a safe landing with only minimal damage was possible. When VH-KXY struck the ground the gear and flaps were retracted and the rate of descent was high. The aircraft was in a level attitude but yawed approximately 45 degrees to the right. After the initial impact, the aircraft slid across the ground on a track of 220 degrees magnetic for 67 metres before coming to rest. There was no post-impact fire. One passenger was able to exit via the cabin door by his own efforts. The other occupants were trapped in the wreckage and were rescued some 30 minutes later by persons who attended the accident. The pilot died shortly after being removed from the aircraft.
Probable cause:
The probable cause of the accident was that, following a substantial loss of power by both engines, the pilot did not carry out the procedures necessary for a safe forced landing. The cause of the loss of power by both engines has not been determined.
Final Report:

Crash of a Swearingen SA226TC Metro II in Esperance

Date & Time: May 13, 1980 at 0745 LT
Type of aircraft:
Operator:
Registration:
VH-SWO
Survivors:
Yes
Schedule:
Perth - Esperance
MSN:
TC-275
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9010
Captain / Total hours on type:
1155.00
Circumstances:
Weather conditions at Esperance were fine; there was no cloud, visibility was in excess of 30 km and the surface wind was from the northwest at 5 to 10 knots. The aircraft entered the circuit on a left downwind leg for an approach to Runway 29. The flaps were lowered, firstly a quarter and then half-way, on the downwind leg and the landing gear was extended just before the aircraft turned onto a base leg. This configuration, and an airspeed of 133 knots (best single - engine rate of climb speed), was maintained until after the aircraft was straightened onto final approach. At an altitude of 1100 feet, the pilot considered he was at Decision Height and committed to land. He lowered full flaps and reduced the airspeed to 115 knots. At about this time, as he was retarding the power levers, the right engine flamed out. The pilot reported that he promptly sensed the engine failure and checked the engine instruments while re-opening both power levers. He noted both torque and fuel flow indication s for the right engine were zero. He briefly considered retracting the landing gear and flaps but decided to do neither. Left engine power was increased initially to the maximum available of 940°C ITT (Inter-turbine temperature) and then adjusted to the normal maximum limit of 923°C ITT. The right propeller was feathered. During this period the aircraft banked to the right and turned away from the runway. Its airspeed had reduced and the rate of descent increased. The turn had been opposed but the pilot found that the application of full left rudder and aileron would not enable him to maintain runway heading, although the airspeed was above the minimum control airspeed of 94 knots, specified in the aircraft flight manual. It was evident to the pilot that the aircraft would land short of the aerodrome, amongst trees to the right of the runway approach path. He therefore abandoned his efforts to regain the normal approach path and allowed the aircraft to turn further to the right, towards a large, clear paddock. Just before touchdown, he observed a power pole on his selected landing path and he again turned further right to avoid it. During this turn the right wing tip struck the ground. The nosegear then impacted heavily and collapsed . The aircraft slid and bounced across the ground for 188 metres before coming to rest. Fuel from ruptured line s ignite d under the left engine , but the fire was slow to develop and the occupants were able to make an orderly evacuation . By the time the fire brigade arrived from Esperance township, the fire had spread and most of the aircraft was consumed.
Probable cause:
The right engine had flamed out because of fuel starvation, when a spur gear in the fuel control drive train failed. Five teeth of the spur gear had broken off and the remaining teeth were badly worn. The failures and abnormal wear were due to looseness of the torque sensor housing, in which the spur gear was mounted, allowing the gear to move out of its correct alignment. The housing had probably loosened because of vibration, as its natural frequency was close to some frequencies generated by the engine during normal operation. The following contributing factors were reported:
- The natural frequency of the torque sensor housings in the engines fitted to VH-SWO were susceptible to vibration frequencies generated by the engines during normal operation,
- Vibration loosened the torque sensor housing on the right engine, which in turn led to misalignment of a spur gear in the fuel drive train, failure of the gear and fuel starvation
of the engine,
- The engine failed when the aircraft was being operated in a landing configuration which precluded a successful continuation of the landing approach,
- The landing procedure used by the pilot was in accordance with the operator's Company Operations Manual, which did not appreciate the poor performance and handing' difficulties of the Swearingen SA226TC in the event of an engine failure in the landing configuration.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Dysart: 1 killed

Date & Time: Feb 26, 1980
Registration:
VH-EGT
Flight Phase:
Flight Type:
Survivors:
No
MSN:
421B-0933
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Crashed on takeoff for unknown reasons. The pilot, sole on board, was killed. He was engaged in a positioning flight.