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:
Birddog 370
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4900
Captain / Total hours on type:
102.00
Aircraft flight hours:
7566
Circumstances:
On the morning of 4 November 2023, a Gulfstream 695A, registered VH-HPY, was being operated by AGAIR on an instrument flight rules flight from Toowoomba to Mount Isa, Queensland. On board the aircraft were the pilot and 2 camera operators. The purpose of the flight was to conduct line scanning of fire zones located north of Mount Isa. About 1 hour and 50 minutes into the flight, while the aircraft was in cruise at flight level 280, air traffic control (ATC) lost radio contact with the pilot. Over the following 30 minutes, ATC made multiple attempts to re-establish contact, including using alternate frequencies and relaying messages via other aircraft in the vicinity. VH-HPY was observed diverging from track and ATC declared an uncertainty phase for the aircraft. About 20 minutes later, ATC called the pilot’s mobile telephone, and a brief conversation took place. During the conversation, the pilot’s speech was observed as slow and flat. In response, ATC upgraded the aircraft’s status to an alert phase and initiated their hypoxic pilot emergency procedures. About 10 minutes later, the crew of a nearby aircraft was able to establish contact with the pilot, having been requested to do so by ATC. The alert phase was downgraded to an uncertainty phase and, a short time later, ATC re-established direct contact with the pilot. The uncertainty phase was cancelled 1 minute later. The pilot confirmed that their oxygen system was operating normally, and they were issued a clearance to undertake line scanning north of Mount Isa. Over the following 4 minutes, the pilot repeated the clearance from ATC 4 times, seeming uncertain about the status of the clearance. The radio recordings during this period indicate that the pilot’s rate and volume of speech had substantially lowered from earlier communications and was worsening. The pilot’s final radio transmission displayed the slowest speaking rate of all their communications during the flight and contained stuttering and operational mistakes. Air traffic control did not attempt to re-establish contact with the pilot until about 18 minutes later, however no further responses from the pilot were received. A short time later, the aircraft departed controlled flight, initially entering a descending anticlockwise turn with an increasing rate of descent. At about 10,500 ft, the aircraft likely transitioned into an aerodynamic spin, with a subsequent average rate of descent of about 13,500 ft/min. The aircraft collided with terrain 55 km south-east of Cloncurry. The 3 occupants were fatally injured, and the aircraft was destroyed by impact forces and a fuel-fed post-impact fire.
Probable cause:
Contributing factors
- The pilot's ability to safely operate the aircraft was almost certainly significantly degraded by the onset of altitude hypoxia.
- While in cruise at flight level 280, both power levers were probably reduced without an appropriate descent rate being initiated, resulting in a progressive reduction of airspeed.
- The aircraft entered a descending anticlockwise turn with an increasing rate of descent. At about 10,500 ft, control input(s) were almost certainly made, probably an attempt to recover, that transitioned the aircraft from a high-speed descent to a spin condition that was likely unrecoverable and which continued until the impact with terrain.
- The pilot had a normalized practice of operating VH-HPY with a cabin altitude that required the use of supplemental oxygen. These flights were conducted without access to a suitable oxygen supply, significantly increasing the risk of altitude hypoxia induced incapacitation.
- The aircraft's pressurization system probably did not attain the required cabin altitude when operating at flight level 280 during the accident flight. The pilot probably knowingly continued the flight with a cabin altitude that required the use of supplemental oxygen, without access to a suitable oxygen supply.
- The AGAIR aircraft VH-HPY pressurization system could not reliably attain the required cabin altitude during flight due to a known, long-term, unresolved intermittent defect. AGAIR management personnel were aware of the defect and, through a combination of inaction, encouragement and, in some instances direct involvement, permitted the aircraft to continue operations at an excessive cabin altitude. (Safety issue)
- AGAIR management exercised ineffective operational control over the line scanning activities. As a result, the ongoing intermittent pressurization defect was not formally recorded, the issues with the aircraft were not communicated to the AGAIR safety manager, and the hazardous practice of operating the aircraft at a cabin altitude that required the use of supplemental oxygen, without access to a suitable oxygen supply, was allowed to continue. (Safety issue)
- The AGAIR head of flying operations did not communicate critical safety information about the known intermittent pressurization defect on VH-HPY when they were phoned by air traffic control about concerns that the pilot may be impacted by hypoxia.
- After being told by the pilot that operations were normal, controllers likely reduced their vigilance about hypoxia and did not re-identify the possibility of hypoxia during the subsequent progressive deterioration of the pilot’s speech.
Other factors that increased risk:
- AGAIR Gulfstream 690 and 695 aircraft were operated with known defects without being recorded on the aircraft’s maintenance releases, likely as a routine practice. For VH-HPY, the absence of documented historical information limited the ability to assess the operational impact of the pressurization defect and the effectiveness of maintenance rectification activities. (Safety issue)
- The Airservices Australia hypoxic pilot emergency checklist did not contain guidance on ceasing the emergency response. This increased the risk that a controller may inappropriately downgrade the emergency response during a developing hypoxic scenario. (Safety issue)
Other finding:
- A 2019 Civil Aviation Safety Authority surveillance event of AGAIR triggered by concerns reported by an AGAIR pilot, including delayed rectification of airworthiness issues, did not include a crosscheck of maintenance releases against the aircraft logbooks, which limited the surveillance team’s ability to determine whether any non-reporting and improper deferral of defects had been taking place at that time.
Final Report:

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

Date & Time: Apr 7, 2023 at 0605 LT
Operator:
Registration:
VH-HJE
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
Captain / Total flying hours:
1473
Captain / Total hours on type:
204.00
Circumstances:
On 7 April 2023, the pilot of a Piper Aircraft Corporation PA-31-350 Chieftain (PA-31), registered VH-HJE and operated by Air Link, was conducting a freight charter flight from Archerfield, Queensland. The planned flight included one intermediate stop at Bankstown, New South Wales before returning to Archerfield, and was conducted under the instrument flight rules at night. The aircraft departed Archerfield at about 0024 local time and during the first leg to Bankstown, the pilot reported an intermittent fault with the autopilot, producing uncommanded pitch changes and associated rates of climb and descent of around 1,000 ft/min. As a result, much of the first leg was flown by hand. After landing at Bankstown at about 0248, a defect entry was made on the maintenance release; however, the pilot was confident that they would be able to hand fly the aircraft for the return leg and elected to continue with the planned flight. The aircraft was refueled to its maximum capacity for the return leg after which a small quantity of water was detected in the samples taken from both main fuel tanks. Additional fuel drains were conducted until the fuel sample was free of water. The manifested freight for the return leg was considered a light load and the aircraft was within weight and balance limitations. After taking off at 0351, the pilot climbed to the flight planned altitude of 9,000 ft. Once established in cruise, the pilot changed the left and right fuel selectors from the respective main tank to the auxiliary tank. The pilot advised that, during cruise, they engaged the autopilot and the uncommanded pitch events continued. Consequently, the pilot did not use the autopilot for part of the flight. Approaching top of descent, the pilot recalled conducting their normal flow checks by memory before referring to the checklist. During this time, the pilot completed a number of other tasks not related to the fuel system, such as changing the radio frequency, checking the weather at the destination and briefing themselves on the expected arrival into Archerfield. Shortly after, the pilot remembered changing from the auxiliary fuel tanks back to the main fuel tanks and using the fuel quantity gauges to confirm tank selection. The pilot calculated that 11 minutes of fuel remained in the auxiliary tanks (with an estimated 177 L in each main tank). Around eight minutes after commencing descent and 28 NM (52 km) south of Archerfield (at 0552), the pilot observed the right ‘low fuel flow’ warning light (or ‘low fuel pressure’) illuminate on the annunciator panel. This was followed soon after by a slight reduction in noise from the right engine. As the aircraft descended through approximately 4,700 ft, the ADS-B data showed a moderate deceleration with a gradual deviation right of track. While the power loss produced a minor yaw to the right, the pilot recalled that only a small amount of rudder input was required to counter the adverse yaw once the autopilot was disconnected. Without any sign of rough running or engine surging, they advised that had they not seen the annunciator light, they would not have thought there was a problem. Over the next few minutes, the pilot attempted to troubleshoot and diagnose the problem with the right engine. Immediately following power loss, the pilot reported they:
• switched on both emergency fuel boost pumps
• advanced both mixture levers to RICH
• cycled the throttle to full throttle and then returned it to its previous setting without fully closing the throttle
• moved the right fuel selector from main tank to auxiliary
• disconnected the autopilot and retrimmed the aircraft. This did not alter the abnormal operation of the right engine, and the pilot conducted the engine roughness checklist from the aircraft pilot’s operating handbook noting the following:
• oil temperature, oil pressure, and cylinder head temperature indicated normally
• manifold absolute pressure (MAP) had decreased from 31 in Hg to 27 inHg
• exhaust gas temperature (EGT) indicated in the green range
• fuel flow indicated zero.
With no indication of mechanical failure, the pilot advised they could not rule out the possibility of fuel contamination and chose not to reselect the main tank for the remainder of the flight. After considering the aircraft’s performance, handling characteristics and engine instrument indications, the pilot assessed that the right engine, while not able to generate normal power, was still producing some power and that this would assist in reaching Archerfield. Based on the partial power loss diagnosis, the pilot decided not to shut down and secure the engine which would have included feathering the propeller. At 0556, at about 20 NM south of Archerfield at approximately 3,300 ft, the pilot advised air traffic control (ATC) that they had experienced an engine malfunction and requested to maintain altitude. With maximum power being set on the fully operating left engine, the aircraft was unable to maintain height and was descending at about 100 ft/min. Even though the aircraft was unable to maintain height, the pilot calculated that the aircraft should have been able to make it to Archerfield and did not declare an emergency at that time. At 0602, about 12 minutes after the power loss on the right engine, the left engine began to run rough and the pilot observed the left low fuel flow warning light illuminate on the annunciator panel. This was followed by severe rough running and surging from the left engine which produced a series of pronounced yawing movements. The pilot did not run through the checklist a second time for the left engine, reporting that they completed the remaining item on the checklist for the left engine by switching the left engine’s fuel supply to the auxiliary tank. The pilot once again elected not to change tank selections back to mains. With both engines malfunctioning and both propellers unfeathered, the rate of descent increased to about 1,500 ft/min. The pilot advised that following the second power loss, it was clear that the aircraft would not be able to make it to Archerfield and their attention shifted from troubleshooting and performance management to finding somewhere to conduct a forced landing. ADS-B data showed the aircraft was at about 1,600 ft when the left engine malfunctioned. The pilot stated that they aimed to stay above the minimum control speed, which for VH-HJE was 72 kt. The aircraft was manoeuvred during the brief search), during which time the ground speed fluctuated from 110 kt to a low of 75 kt. It was calculated that in the prevailing wind, this would have provided an approximate indicated airspeed of 71 kt; equal to the aircraft’s clean configuration stall speed. The pilot declared an emergency and advised ATC that they were unable to make Archerfield Airport and would be conducting an off-airport forced landing. With very limited suitable landing areas available, the pilot elected to leave the flaps and gear retracted to minimize drag to ensure they would be able to make the selected landing area. At about 0605, the aircraft touched down in a rail corridor beside the railway line, and the aircraft’s left wing struck a wire fence. The aircraft hit several trees, sustaining substantial damage to the fuselage and wings. The pilot received only minor injuries in the accident and was able to exit through the rear door of the aircraft.
Probable cause:
The following contributing factors were identified:
- It is likely that the pilot did not action the checklist items relating to the selection of main fuel tanks for descent. The fuel supply in the auxiliary tanks was subsequently consumed resulting in fuel starvation and loss of power from the right then left engine.
- Following the loss of power to the right engine, the pilot misinterpreted the engine instrument indications as a partial power loss and carried out the rough running checklist but did not select the main tanks that contained substantial fuel to restore engine power, or feather the propeller. This reduced the available performance resulting in the aircraft being unable to maintain altitude.
- When the left engine started to surge and run rough, the pilot did not switch to the main tank that contained substantial fuel, necessitating an off‑airport forced landing.
- It is likely that the pilot was experiencing a level of fatigue shown to have an effect on performance.
- As the pilot was maneuvering for the forced landing there was a significant reduction of airspeed. This reduced the margin over the stall speed and increased the risk of loss of control.
- Operator guidance material provided different fuel flow figures in the fuel policy and flight crew operating manual for the PA-31 aircraft type.
- The operator’s fuel monitoring practices did not detect higher fuel burns than what was specified in fuel planning data.
- The forced landing site selected minimized the risk of damage and injury to those on the ground and the controlled touchdown maximized the chances of survivability.
Final Report:

Crash of a Pacific Aerospace PAC 750XL in Kudjip

Date & Time: Feb 9, 2023 at 1250 LT
Operator:
Registration:
P2-BJD
Flight Phase:
Survivors:
Yes
Schedule:
Giramben - Simbai
MSN:
124
YOM:
2005
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3582
Captain / Total hours on type:
1885.00
Aircraft flight hours:
13811
Aircraft flight cycles:
17220
Circumstances:
The flight was planned to depart Giramben at 12:40, and track North for Simbai Airstrip, Madang Province at 9,000 ft AMSL. According to the pilot, the aircraft was loaded by NCA ground handlers following his instructions. The manifest was completed by one of the ground handler, who stated that the aircraft was loaded by the other ground handlers while he was completing the manifest in the vehicle, due to no proper shed for him to work from. The pilot also stated that at the time the loading was completed, and the passengers had boarded the aircraft, he observed that the winds were variable, blowing directly from the North and from the East as well. Recorded data showed that the aircraft commenced taxiing at 12:44. During the take-off roll, at the expected airborne point, about 500 m down the runway, as the aircraft accelerated with the airspeed approaching 60 knots, the right wheel hit a soft spot on the strip which dramatically reduced the momentum and speed of the aircraft, as described by the pilot. Eyewitnesses reported seeing the aircraft getting airborne briefly and got back on the ground again. The pilot recalled that by the time the aircraft got back on the ground he realized that he had passed the nominated committal point, which was identified during onsite activities to be about 540 m from the threshold of runway 16. The pilot opted to continue with the take-off roll, with full power hoping that the aircraft would regain speed on the remaining part of the strip to get airborne again. The pilot recalled reaching the end of the runway and getting airborne again with an airspeed of 50 kts airborne again, however, the right wheel got caught on the barbed wire of the perimeter fence that ran across to the runway, and subsequently impacted terrain. The pilot stated that he had lost consciousness at the time of the initial impact and therefore, had no recollection from thereon. The investigation found that the aircraft got airborne about 19 m past the end of runway 16. However, the aircraft’s main landing gears got caught on the perimeter fencing wire, subsequently impacting ground about 100 m from the end of the runway, then continued with the momentum and came to rest, in a local village garden about 160 m from the end of the runway. The aircraft was destroyed by impact forces. The pilot and passengers were rescued by the locals and taken to Nazarene General Hospital, Jiwaka Province, for treatment. The pilot, male adult and infant passengers sustained serious injuries, and the female passenger sustained minor injuries.
Probable cause:
The following factors were identified:
- The pilot did not complete a trim sheet for the flight.
- The manifest was completed by a ground handler who was not present at the time the cargo was being loaded by other ground handlers. The manifest was not signed by the ground handler who completed it, nor was it authorized by the pilot before departure.
- Pilot’s lack of supervision of the aircraft’s loading process to ensure cargo is loaded correctly and in accordance with the prescribed limitations and to prevent calculation errors. As a result, it was likely that the aircraft was overweight when it departed.
- Wet strip surface conditions that caused significant resistance during the take-off roll and impeded the aircraft’s ability to reach its required lift off airspeed.
- Pilot’s decision to continue the take-off roll after passing the committal.
- Training deficiencies of ground handlers and the pilot.
- The lack of adequate Quality Assurance systems oversight on the operator’s operating standard procedures.
Final Report:

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

Date & Time: Feb 6, 2023 at 1614 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
Captain / Total flying hours:
8233
Captain / Total hours on type:
1399.00
Copilot / Total flying hours:
5852
Copilot / Total hours on type:
128
Aircraft flight hours:
69187
Circumstances:
The air tanker, callsign Bomber 139, departed from Busselton Airport, Western Australia (WA) on a firefighting task to Fitzgerald River National Park, WA. There were 2 pilots on board, the aircraft captain in the left seat as the pilot flying and a copilot in the right seat as the pilot monitoring. At about 1614, during the go-around from a second partial retardant drop, the aircraft impacted a ridgeline at an elevation of about 222 ft and subsequently crashed, bursting into flames. The pilots suffered minor injuries and the aircraft was destroyed by a post crash fire.
Probable cause:
The ATSB found that the accident drop was conducted at a low height and airspeed downhill, which required the use of idle thrust and a high descent rate. The delay in the engines reaching go-around thrust at the end of the drop resulted in the aircraft’s height and airspeed (energy state) decaying as it approached rising terrain, which was not expected or detected by the pilot flying. Consequently, the aircraft’s airspeed and thrust were insufficient to climb above a ridgeline in the exit path, which resulted in a controlled flight into terrain. The operator’s practice of recalculating, and lowering, their target drop speed after a partial load drop also contributed to the low energy state of the aircraft leading up to the collision with terrain.
The ATSB also found that the operator and tasking agency had not published a minimum drop height, which resulted in the copilot, who did not believe there was a minimum drop height, not making any announcements about the low energy state prior to the collision. The ATSB found the operator’s pilot monitoring duties were reactive to the development of a low energy state and did
not include call-outs either before or at the minimum target parameters to reduce the risk of a low energy state developing.
The ATSB benchmarked the WA, New South Wales and National Aerial Firefighting Centre standards against the United States Forest Service and United States National Wildfire Coordinating Group standards and found inconsistencies between the Australian agencies’ standards but not among the United States agencies’ standards. This was likely a result of each Australian state participating in the LAT program independently producing their own standards.
Final Report:

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

Date & Time: Oct 3, 2022 at 1338 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
Captain / Total flying hours:
2400
Captain / Total hours on type:
250.00
Aircraft flight hours:
14081
Circumstances:
On the afternoon of 3 October 2022, a Pilatus Britten-Norman Islander BN2A-21, registered VHWQA and operated by Torres Strait Air, was conducting a non-scheduled passenger air transport flight from Saibai Island Airport, Queensland (QLD) to Horn Island Airport, QLD. There was 1 pilot and 6 passengers (students) on board. About 19 km NE of Moa Island both engines began to surge. The pilot diverted towards Kubin Airport on Moa Island. As the aircraft passed to the south of the township of Saint Pauls, the pilot determined there was insufficient altitude remaining to reach the airport. As a result, the pilot conducted a forced landing on a road 7 km ENE of Kubin Airport. There were no reported injuries to the pilot or the passengers. The aircraft was substantially damaged.
Probable cause:
The ATSB found that the dual engine speed fluctuations and associated power loss was probably the result of fuel starvation. The mechanism was not conclusively determined, however it was identified that the pilot did not operate the aircraft's fuel system in accordance with the aircraft flight manual, and that the configuration and location of the aircraft’s fuel controls and tank quantity gauges were probably not conducive to rapid and accurate interpretation. The aircraft manufacturer released a service letter in June 2022 that detailed an optional modification to centralize the fuel system controls and gauges, however this modification was not fitted to VH-WQA. The ATSB considered that these factors increased the risk of inadvertent fuel tank selection.
Final Report:

Crash of a Pacific Aerospace PAC 750XL in Tekin

Date & Time: Jan 26, 2022 at 0943 LT
Operator:
Registration:
P2-BWC
Survivors:
Yes
Schedule:
Kiunga – Oksapmin
MSN:
136
YOM:
2007
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14129
Captain / Total hours on type:
3625.00
Aircraft flight hours:
6752
Aircraft flight cycles:
13861
Circumstances:
The airplane was on a VFR charter flight from Kiunga Airport, Western Province to Tekin Airstrip, Sandaun Province, Papua New Guinea. During the landing roll aircraft sustained a left main landing gear assembly collapse and subsequent runway excursion. There were seven persons onboard: one pilot and six passengers. At 09:06, P2-BWC departed Kiunga Airport and arrived at Tekin circuit area at 09:40. The pilot established the aircraft on the final approach profile, he configured the aircraft for landing by fully extending the flaps and maintained an airspeed of about 80 knots (kts). The pilot also stated that he experienced a downdraft prior to touch down. The aircraft landed at 09:43 with an airspeed of 75 knots as recalled by the pilot. The aircraft touched down about 3m short of the airstrip edge boundary. The investigation determined that due to reduced damping effect of the oleo and/or the tyre of the left main landing gear, the landing gear attachment bolts sustained significant impact stress from the landing impact force and snapped, causing the gear assembly to collapse and separate from the aircraft. Subsequently, the left wing abruptly dropped, and the aircraft began veering to the left, towards the eastern edge of the airstrip. The aircraft continued veering to the left and subsequently the left wingtip struck the outer edge of the extended right-hand flap of P2-BWE, a wreckage of the same aircraft type owned and operated by NASL that was involved in a similar accident on 18 January 2022, causing P2-BWC to abruptly veer further left and skid across the airstrip boundary as the nose-wheel and right main wheel bogged into the ground. The pilot immediately shut down the engine and evacuated the passengers with the assistance of one of the Operator’s personnel who was also a passenger on board. There were no reported injuries and the aircraft sustained significant damage.
Probable cause:
During the landing at Tekin Airstrip, the pilot encountered downdraft and touchdown about 4 metres short of the designated landing threshold. Due to less damping effect on the oleo or the tyre, the landing impact force could have transferred up through the structure and concurrently causing the left main landing gear to collapse. Subsequently, the left wing abruptly dropped and began veering to the left, towards the eastern edge of the airstrip. The aircraft continued veering to the left and subsequently the left wingtip struck the outer edge of the extended right-side flap of P2-BWE, causing it to abruptly veer further left and skid across the airstrip boundary as the nose-wheel and right main wheel bogged into the ground.
Final Report:

Crash of a Pacific Aerospace PAC 750XL in Tekin

Date & Time: Jan 18, 2022 at 0926 LT
Operator:
Registration:
P2-BWE
Survivors:
Yes
Schedule:
Kiunga – Oksapmin
MSN:
161
YOM:
2009
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9305
Captain / Total hours on type:
332.00
Aircraft flight hours:
7549
Aircraft flight cycles:
11178
Circumstances:
The airplane was conducting a single pilot VFR charter flight from Kiunga Airport, Western Province to Tekin Airstrip, Sandaun Province, Papua New Guinea when during the landing roll, the aircraft sustained a left Main Landing Gear (MLG) assembly collapse and subsequent runway excursion. There were eight persons onboard: one pilot and seven passengers. At 08:43, P2-BWE departed Kiunga Airport and arrived at Tekin Airstrip circuit at 09:18. The pilot then tracked towards the Northwest of the airstrip and made a left base turn for approach. The pilot stated that he established the aircraft on final approach with an airspeed of 120 kts. He subsequently configured the aircraft for landing; propeller pitch set to full fine, power set to maintain nominated approach speed, and full flap. The pilot indicated that he reduced airspeed while on approach and maintained an airspeed between 85 and 90 kts. As he flared the aircraft to land, the airspeed was between 75 to 80 kts. The touchdown speed, as he recalled, was 75 kts. The aircraft touched down two metres short of the designated landing threshold of runway18, which had an elevation of 15cm. Reviewing the flight records of the pilot, and from his interview, the AIC deduced that the pilot was not adequately familiar with Tekin Airstrip. The aircraft sustained substantial damaged. All the passengers and pilot evacuated the aircraft without injuries.
Probable cause:
The investigation identified that during touchdown, the aircraft’s main landing gear tyre hit the 15cm elevation at the edge of runway18, resulting in the left MLG assembly weakening. The investigation determined that due to less damping effect on the oleo or the tyre, the landing impact force could have transferred up through the structure and concurrently causing the left MLG assembly to collapse. Following the collapse of the left MLG assembly, the left-wing assembly dropped and hit the ground, the flap detached and began to drag on the surface of the strip creating markings. The aircraft immediately began veering left, towards the edge (boundary) of the airstrip and impacted the drainage ditch adjacent to the runway where it came to rest.
Final Report:

Crash of a Cessna 402C in Papa Lealea

Date & Time: Jul 26, 2020 at 1246 LT
Type of aircraft:
Operator:
Registration:
VH-TSI
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Papa Lealea - Mareeba
MSN:
402C-0492
YOM:
1981
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 26 July 2020, at 12:46 local time (02:46 UTC), a Cessna 402C aircraft, registered VH-TSI collided with trees during an aborted take-off at an uncommissioned field near Papa-Lealea, about 16 nm North-West of Port Moresby, Papua New Guinea. The pilot, during interview with the AIC, stated that he departed at 09:30 that day from Mareeba Airport, Queensland Australia and tracked towards the North North-East with a planned track set slightly left of Jacksons International Airport, Port Moresby, National Capital District, Papua New Guinea. As the aircraft neared the Southern shoreline (within the Caution Bay area), he diverted left and began tracking towards the North West along the coast in order to avoid flying over villages in the area. He subsequently crossed over land before turning back to approach the intended landing field. As the aircraft approached to land, the outboard section of the left wing was clipped by a tree and separated from the aircraft. According to the pilot, he continued on with the approach and landed on the field at about 12:20. The pilot reported that he had flown to and within Papua New Guinea in the past and was familiar with the area and airspace. He confirmed that after departing Mareeba, he switched off the transponder. After shutting down the aircraft, the aircraft was refuelled with jerrycans full of fuel (AvGas) and loaded with cargo by persons waiting on the ground. The pilot reported that he estimated that a distance of 800 m would be required for the take-off. According to the pilot, at about 12:40, he lined up and commenced his take-off roll from the Southern end of the field. As the aircraft lifted off, he noticed that the airspeed indicator (ASI) was not working. He also observed that the aircraft was not achieving a positive rate of climb. He subsequently pulled the throttles back and manoeuvred the aircraft back towards the ground. The aircraft touched down with a speed that the pilot described as higher than normal, with about 400 m of usable field remaining. The aircraft continued off the end of the field and into the bushes clipping trees along the way until it came to rest. The pilot informed the AIC that he was the sole occupant of the aircraft, and sustained minor injuries as a result of the occurrence. The aircraft was substantially damaged. The investigation confirmed that the fire to the left wing and engine was a post-accident event and was deliberate. The pilot was later arrested and a load of 500 kilos of cocaine distributed in 28 bales was found at the scene.
Probable cause:
The investigation determined that the separation of the outboard section of the left wing, clipped by a tree during the approach to land phase, affected the ability of the left wing to produce lift. The investigation could not conclusively determine the actual weight and balance of the aircraft as it was not possible to determine the quantity and quality of fuel on board, nor the weight and distribution of the cargo that was on board. The evidence gathered during the investigation did not allow the AIC to discard overweight, balance or centre of gravity issues due to improper loading or restrain of the cargo as factors contributing to the inability of the aircraft to obtain a positive rate of climb during take-off. The evidence of tire marks found by the investigators on the uncommissioned field indicated that the aircraft touched down about 400 m before the end of the field, distance that was not enough for the aircraft to come to a stop, continuing its landing roll into the bushes and impacting trees until it got to its final position. The investigation determined that the aircraft was not airworthy at the time of the accident and was unserviceable for the conduct of the flight. The investigation also determined that there was no proper document control to conduct timely scheduled maintenance and that there was no record of a certificate of airworthiness (CoA) at the time of the accident.
Final Report:

Crash of a PAC Cresco 08-600 near Carterton: 1 killed

Date & Time: Apr 24, 2020 at 0710 LT
Type of aircraft:
Operator:
Registration:
ZK-LTK
Flight Phase:
Survivors:
No
Site:
MSN:
30
YOM:
2002
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
15000
Captain / Total hours on type:
8700.00
Circumstances:
On 24 April 2020 the pilot of a Pacific Aerospace Cresco 08-600 aircraft, registered ZK-LTK (the aeroplane), was conducting agricultural flight operations spreading superphosphate fertilizer on a farm in the Kourarau Hill area, near Masterton. The airstrip was a typical topdressing airstrip, with a downward slope and a left bend of about 5 degrees partway down the strip, in the direction of take-off. The ground at the end of the airstrip dropped sharply away to a valley that ran perpendicular to the direction of the airstrip. On the commencement of the third topdressing flight, witnesses reported, the aeroplane accelerated normally from the loading point. However, the aeroplane did not follow the direction of the airstrip around to the left, as it had done during the previous two flights. Instead, the aeroplane continued in a straight line from the load point and subsequently struck uneven terrain off to the right of the airstrip. The impact with the uneven terrain caused the right main undercarriage assembly to fracture off and damage the right wing and flap. The aeroplane descended into the valley, striking a tree with the right-hand wing, then continued across the valley floor and impacted the far side of the valley, coming to rest inverted. The aeroplane was destroyed by the impacts and a post-crash fire. The sole pilot occupant did not survive the accident sequence.
Probable cause:
The following findings were identified:
- The pilot did not make the necessary left turn during the take-off roll to align with the strip centreline, so the aeroplane continued the take-off roll in a straight line.
- The right-rear undercarriage struck uneven ground with sufficient force to break the undercarriage mounting brackets and dislodge the undercarriage assembly from the aeroplane.
- The right main undercarriage subsequently struck the right flap, resulting in a partial dislocation of the flap. This very likely resulted in the aeroplane becoming uncontrollable.
- The pilot was about as likely as not to have been incapacitated early in the take-off roll.
Final Report:

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: