Australia

From the evidence available, the following findings are made with respect to the fuel starvation event and should not be read as apportioning blame or liability to any particular organisation or individual.
- The pilot did not monitor outboard fuel tank quantity during the flight.
- The pilot incorrectly diagnosed the engine power losses.
- The aircraft was not in the correct configuration for the forced landing.

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.

Contributing safety factors:
• The aircraft probably entered an area of weather that deteriorated below visual meteorological conditions and for which the pilot was not experienced or qualified.
• The pilot probably became unsure of his position in poor visibility, leading to controlled flight into terrain, fatally injuring the pilot and destroying the aircraft.
Other safety factors:
• The aircraft had not been configured for poor visibility operations, possibly increasing the pilot’s difficulty in navigating.
• The pilot did not submit any form of flight notification such as a SARTIME or Flight Note, as required for a flight in a designated remote area, resulting in a delay to the search and rescue response.
• The operator did not have procedures to provide assurance that a search and rescue would be initiated in a timely way if one of their aircraft did not arrive at the planned destination. [Safety issue]
• As a result of damage to the emergency locator beacon antenna, the beacon did not alert search and rescue organisations to the aircraft accident.

Structural failure and damage:
From the detailed examination and study of the aircraft wreckage undertaken by ATSB investigation staff, it was evident that all principal structural failures had occurred under gross overstress conditions i.e. stresses significantly in excess of the physical strength of the respective structures. The examination found no evidence of pre-existing cracking, damage or material degradation that could have appreciably reduced the strength of the failed sections, nor was there any indication that the original manufacture, maintenance or repair processes carried out on the aircraft were in any way contributory to the failures sustained.

Breakup sequence:
From the localised deformation associated with the spar failures, it was evident that the aircraft had sustained a large negative (downward) loading on the wing structure. That downward load resulted in the localised bending failure of the wing around the station 145 position (145” outboard of the aircraft centreline). The symmetry of both wing failures and the absence of axial twisting within the fuselage section suggested that the load encountered was sudden and well in excess of the ultimate strength of the wing structure. Based upon the witness marks on both wing under-surfaces and the crushing and paint transfer along the leading edges of the horizontal stabilisers, it was concluded that after separating from the inboard structure, both wings had moved aft in an axial twisting and rotating fashion; simultaneously impacting the leading edges of both horizontal tailplanes. Forces imparted into the empennage structure from that impact subsequently produced the rearward separation of the complete empennage from the fuselage. The loss of the left engine nacelle fairing was likely brought about through an impact with a section of wing leading edge as it rotated under and to the rear. The damage sustained by all of the aircraft‟s control surfaces was consistent with failure and separation from their respective primary structure under overstress conditions associated with the breakup of the aircraft. There was no evidence of cyclic or oscillatory movement of the surfaces before separation that might have suggested the contribution of an aerodynamic flutter effects.

Findings
The following statements are a summary of the verified findings made during the progress of the aircraft wreckage structural examination and analysis:
- All principal failures within the aircraft wings, tailplanes and empennage had occurred as a result of exposure to gross overstress conditions.
- The damage sustained by the aircraft wreckage was consistent with the aircraft having sustained multiple in-flight structural failures.
- The damage sustained by the aircraft wreckage was consistent with the structural failure sequence being initiated by the symmetric, downward bending failure of both wing sections, outboard of the engine nacelles.
- Breakup and separation of the empennage was consistent with having been initiated by impact of the separated outboard wings with the leading edges of the horizontal stabilisers.
- There was no evidence of material or manufacturing abnormalities within the aircraft structure that could be implicated in the failures and breakup sustained.
- There was no evidence of service-related degradation mechanisms (such as corrosion, fatigue cracking or environmental cracking) having affected the aircraft structure in the areas of failure.

From the evidence available, the investigation revealed that two major system components had failed which could have prevented the Beechcraft Super King Air 200 landing gear from properly retracting after takeoff. The following findings with respect to those failed landing gear system components should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing safety factors:
• The left torque tube support bearing had not been lubricated and had seized due to the accumulation of dirt and grit contaminants that had migrated from the external service environment and into the bearing.
• The geared components within the right main landing gear actuator prematurely failed.
Other safety factors:
• The aircraft manufacturer’s maintenance manual contained insufficient instruction or guidance for operators and maintainers of Super King Air 200 aircraft for the lubrication of the landing gear torque tube support bearings.
Other key findings:
• Both component assemblies were integral to the function and normal operation of the Super King Air 200 mechanical landing gear system. A break down of either component assembly would have prevented any attempt by the pilot to retract or extend the aircraft’s main landing gear. However, while either failure could have produced the landing gear difficulties sustained, the investigation was not able to determine which mechanism was the principal contributor to the event.
• The investigation was unable to conclusively establish why the geared components within the right main landing gear actuator had prematurely failed.
• The lower thrust bearing within the right main landing gear actuator had been correctly installed.

Loss of control during initial climb following a bird strike.

From the evidence available, the following findings are made with respect to the loss of control event involving Piper Aircraft Corporation PA-31-350 aircraft registered VH-ZGZ and should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing safety factors:
• The aircraft diverged left from a steady, controlled descent and entered a steep, left spiral descent from which recovery was not achieved.
Other safety factors:
• The dark and very likely cloudy conditions that existed in the area where the aircraft suddenly diverged from its flight path meant that recovery to normal flight could only have been achieved by sole reference to the aircraft’s flight instruments. The difficulty associated with such a task when the aircraft was in a steep descent was likely to have been significant.

ATSB did not conduct any investigations on this event.

Contributing factors:
• A line of thunderstorms crossed the aircraft’s intended track.
• The aircraft was operating in the vicinity of thunderstorm cells.
• In circumstances that could not be determined, the aircraft’s load limits were exceeded, causing structural failure of the airframe.
Other safety factors:
• Air traffic control procedures, did not require the SIGMET information to be passed to the aircraft.
• There were shortcomings in the Airservices Australia Hazard Alert procedures and guidelines for assessing SIGMET information.
• Air traffic control procedures for the dissemination of SIGMET information contained in the Aeronautical Information Publication were inconsistent with procedures contained in International Civil Aviation Organization (ICAO) Doc. 4444 and ICAO Doc. 7030.
Other key findings:
• The aircraft was not equipped with weather radar or lightning strike detection systems.
• The pilot did not make any request for additional information regarding the weather to air traffic services.
• The pilot in command was occupying the right cockpit seat and the observer- pilot the left cockpit seat at the time of the breakup, but that arrangement was not considered to have influenced the development of the accident.

Findings:
• There were no indications prior to, or during the flight, of problems with any aircraft systems that may have contributed to the circumstances of the occurrence.
• The pilot continued flight into forecast and known icing conditions in an aircraft not approved for flight in icing conditions.
• The global navigation satellite constellation was operating normally.
• The pilot did not comply with the requirements of the published instrument approach procedure.
• The pilot was known, by his Chief Pilot and others, to adopt non-standard approach procedures to establish his aircraft clear of cloud when adverse weather conditions existed at Mount Hotham.
• The pilot may have been experiencing self-imposed and external pressures to attempt a landing at Mount Hotham.
• Terrain features would have been difficult to identify due to a heavy layer of snow, poor visibility, low cloud, continuing heavy snowfall, drizzle, sleet and approaching end of daylight.
• The pilot’s attitude, operational and compliance practices had been of concern to some Airservices’ staff.
• The operator’s operational and compliance history was recorded by CASA as being of concern, and as a result CASA staff continued to monitor the operator. However, formal surveillance of the operator in the preceding two years had not identified any significant operational issues.
Significant factors:
• The weather conditions at the time of the occurrence were extreme.
• The extreme weather conditions were conducive to visual illusions associated with a flat light phenomenon.
• The pilot did not comply with the requirements of flight under either the instrument flight rules (IFR) or the visual flight rules (VFR).
• The pilot did not comply with the requirements of the published instrument approach procedure and flew the aircraft at an altitude that did not ensure terrain clearance.
• The aircraft accident was consistent with controlled flight into terrain.