Ground fire of a GippsAero GA8 Airvan in Gibb River

Date & Time: Apr 22, 2017 at 1255 LT
Type of aircraft:
Operator:
Registration:
VH-AJZ
Flight Type:
Survivors:
Yes
Schedule:
Derby - Gibb River
MSN:
GA8-05-96
YOM:
2005
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 22 April 2017, a Gippsland Aeronautics GA-8 aircraft, registered VH-AJZ, was being used to conduct incendiary bombing aerial work operations in the Prince Regent River area of northern Western Australia (WA). On board were a pilot, a navigator seated in the co-pilot seat and a bombardier in the rear of the aircraft cabin. While conducting the incendiary bombing operations, the bombardier advised the pilot that he was suffering from motion sickness. The pilot elected to land at Gibb River aircraft landing area (ALA), WA, to take a lunch break and provide the bombardier with time to recover from the motion sickness. At about 1255 Western Standard Time (WST), the aircraft landed on runway 07 at Gibb River. During the landing roll, the engine failed. The aircraft had sufficient momentum to enable the pilot to turn the aircraft around on the runway and begin to taxi to the parking area at the western end of runway 07. Shortly after turning around, the aircraft came to rest on the runway. The pilot attempted to restart the engine, but the engine did not start. The pilot waited about 10–20 seconds before again attempting to restart the engine. While attempting the second restart of the engine, the pilot heard a loud noise similar to that of a backfire. The navigator then observed flames and smoke coming from around the front of the engine and immediately notified the pilot. After being notified of the fire, the pilot immediately shut down the engine and switched off the aircraft electrical system. As the pilot switched off the aircraft electrical system, the navigator located the aircraft fire extinguisher and evacuated from the aircraft through the co-pilot door. After evacuating from the aircraft, the navigator observed fire on the aircraft nose wheel. The navigator had difficulty preparing the fire extinguisher for use and was unable to discharge the fire extinguisher onto the fire. While the navigator was attempting to extinguish the fire, the pilot exited the aircraft through the pilot door and assisted the bombardier to exit the aircraft. After assisting the bombardier, the pilot moved to the front of the aircraft to assist the navigator with the firefighting. The pilot was able to activate the fire extinguisher and extinguished the fire on the nose wheel. The pilot observed fire continuing to burn within the engine compartment. Due to the heat of the fire, the pilot was unable to access the engine compartment to extinguish this fire. The pilot determined that no more could be done to contain the fire, and therefore, the pilot, navigator and bombardier moved clear of the aircraft to a safe location as the fire continued. The crew members were not injured. As a result of the fire, the aircraft was destroyed.
Probable cause:
These findings should not be read as apportioning blame or liability to any particular organisation or individual.
- The cause of the engine failure and fire could not be determined.
- After the fire was identified, two steps in the emergency procedure were omitted. This included not closing the fuel shutoff valve, which likely resulted in the fire not being extinguished and subsequently intensifying.
Final Report:

Crash of a Beechcraft B200 Super King Air in Melbourne: 5 killed

Date & Time: Feb 21, 2017 at 0858 LT
Registration:
VH-ZCR
Flight Phase:
Survivors:
No
Site:
Schedule:
Melbourne - King Island
MSN:
BB-1544
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
7681
Captain / Total hours on type:
2400.00
Aircraft flight hours:
6997
Circumstances:
On 21 February 2017, the pilot of a Beechcraft B200 King Air aircraft, registered VH-ZCR (ZCR), and operated by Corporate & Leisure Aviation, was conducting a charter passenger flight from Essendon Airport, Victoria to King Island, Tasmania. There were four passengers on board. ZCR had been removed from a hangar and parked on the apron the previous afternoon in preparation for the flight. The pilot was first seen on the apron at about 0706 Eastern Daylight-saving Time. Closed-circuit television recorded the pilot walking around the aircraft and entering the cabin, consistent with conducting a pre-flight inspection of the aircraft. At about 0712, the pilot entered ZCR’s maintenance provider’s hangar. A member of staff working in the hangar reported that the pilot had a conversation with him that was unrelated to the accident flight. The pilot exited the hangar about 0715 and had a conversation with another member of staff who reported that their conversation was also unrelated to the accident flight. The pilot then returned to ZCR, and over the next 4 minutes he was observed walking around the aircraft. The pilot went into the cabin and re-appeared with an undistinguishable item. The pilot then walked around the aircraft one more time before re-entering the cabin and closing the air stair cabin door. At about 0729, the right engine was started and, shortly after, the left engine was started. Airservices Australia (Airservices) audio recordings indicated that, at 0736, the pilot requested a clearance from Essendon air traffic control (ATC) to reposition ZCR to the southern end of the passenger terminal. ATC provided the clearance and the pilot commenced taxiing to the terminal. At the terminal, ZCR was refueled and the pilot was observed on CCTV to walk around the aircraft, stopping at the left and right engines before entering the cabin. The pilot was then observed to leave the aircraft and wait for the passengers at the terminal. The passengers arrived at the terminal at 0841 and were escorted by the pilot directly to the aircraft. At 0849, the left engine was started and, shortly after, the right engine was started. At 0853, the pilot requested a taxi clearance for King Island, with five persons onboard, under the instrument flight rules. ATC instructed the pilot to taxi to holding point 'TANGO' for runway 17, and provided an airways clearance for the aircraft to King Island with a visual departure. The pilot read back the clearance. Airservices Automatic Dependent Surveillance Broadcast (ADS-B) data (refer to section titled Air traffic services information - Automatic Dependent Surveillance Broadcast data) indicated that, at 0854, ZCR was taxied from the terminal directly to the holding point. The aircraft did not enter the designated engine run-up bay positioned near holding point TANGO. At 0855, while holding at TANGO, the pilot requested a transponder code. The controller replied that he did not have one to issue yet. Two minutes later the pilot contacted ATC and stated that he was ready and waiting for a transponder code. The controller responded with the transponder code and a clearance to lineup on runway 17. At 0858, ATC cleared ZCR for take-off on runway 17 with departure instructions to turn right onto a heading of 200°. The pilot read back the instruction and commenced the takeoff roll. The aircraft’s take-off roll along runway 17 was longer than expected. Witnesses familiar with the aircraft type observed a noticeable yaw to the left after the aircraft became airborne. The aircraft entered a relatively shallow climb and the landing gear remained down. The shallow climb was followed by a substantial left sideslip, while maintaining a roll attitude of less than 10° to the left. Airservices ADS-B data indicated the aircraft reached a maximum height of approximately 160 ft above ground level while tracking in an arc to the left of the runway centreline. The aircraft’s track began diverging to the left of the runway centreline before rotation and the divergence increased as the flight progressed. Following the sustained left sideslip, the aircraft began to descend and at 0858:48 the pilot transmitted on the Essendon Tower frequency repeating the word ‘MAYDAY’ seven times in rapid succession. Approximately 10 seconds after the aircraft became airborne, and 2 seconds after the transmission was completed, the aircraft collided with the roof of a building in the Essendon Airport Bulla Road Precinct - Retail Outlet Centre (outlet centre), coming to rest in a loading area at the rear of the building. CCTV footage from a camera positioned at the rear of the building showed the final part of the accident sequence with post-impact fire evident; about 2 minutes later, first responders arrived onsite. At about 0905 and 0908 respectively, Victoria Police and the Metropolitan Fire Brigade arrived. The pilot and passengers were fatally injured and the aircraft was destroyed. There was significant structural, fire and water damage to the building. Additionally, two people on the ground received minor injuries and a number of parked vehicles were damaged.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain involving Beechcraft B200 King Air, registered VH-ZCR that occurred at Essendon Airport, Victoria on 21 February 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factors:
- The aircraft's rudder trim was likely in the full nose-left position at the commencement of the take-off.
- The aircraft's full nose-left rudder trim setting was not detected by the pilot prior to take-off.
- Following a longer than expected ground roll, the pilot took-off with full left rudder trim selected. This configuration adversely affected the aircraft's climb performance and controllability, resulting in a collision with terrain.

Other factors that increased risk:
- The flight check system approval process did not identify that the incorrect checklist was nominated in the operator’s procedures manual and it did not ensure the required checks, related to the use of the cockpit voice recorder, were incorporated.
- The aircraft's cockpit voice recorder did not record the accident flight, resulting in a valuable source of safety related information not being available.
- The aircraft's maximum take-off weight was likely exceeded by about 240 kilograms.
- Two of the four buildings within the Bulla Road Precinct Retail Outlet Centre exceeded the obstacle limitation surface (OLS) for Essendon Airport, however, the OLS for the departure runway was not infringed and VH-ZCR did not collide with those buildings.

Other findings:
- The presence of the building struck by the aircraft was unlikely to have increased the severity of the outcome of this accident.
- Both of the aircraft’s engines were likely to have been producing high power at impact.
Final Report:

Crash of a Grumman G-73 Mallard in Perth: 2 killed

Date & Time: Jan 26, 2017 at 1708 LT
Type of aircraft:
Operator:
Registration:
VH-CQA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Serpentine - Serpentine
MSN:
J-35
YOM:
1948
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
625
Captain / Total hours on type:
180.00
Circumstances:
On 26 January 2017, the pilot of a Grumman American Aviation Corp G-73 amphibian aircraft, registered VH-CQA (CQA), was participating in an air display as part of the City of Perth Australia Day Skyworks event. On board were the pilot and a passenger. The pilot of CQA was flying ‘in company’ with a Cessna Caravan amphibian and was conducting operations over Perth Water on the Swan River, that included low-level passes of the Langley Park foreshore. After conducting two passes in company, both aircraft departed the display area. The pilot of CQA subsequently requested and received approval to conduct a third pass, and returned to the display area without the Cessna Caravan. During positioning for the third pass, the aircraft departed controlled flight and collided with the water. The pilot and passenger were fatally injured.
Probable cause:
From the evidence available, the following findings are made regarding the loss of control and collision with water involving the G-73 Mallard aircraft, registered VH-CQA 10 km west-south-west of Perth Airport, Western Australia on 26 January 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual. Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.
Contributing factors:
- The pilot returned the aircraft to the display area for a third pass in a manner contrary to the approved inbound procedure and which required the use of increased manoeuvring within a confined area to establish the aircraft on the display path.
- During the final positioning turn for the third pass, the aircraft aerodynamically stalled at an unrecoverable height.
- The pilot's decision to carry a passenger on a flight during the air display was contrary to the Instrument of Approval issued by the Civil Aviation Safety Authority for this air display and increased the severity of the accident consequence.
Final Report:

Crash of a Beechcraft B200 Super King Air in Moomba

Date & Time: Dec 13, 2016 at 1251 LT
Operator:
Registration:
VH-MVL
Flight Type:
Survivors:
Yes
Schedule:
Innamincka – Moomba
MSN:
BB-1333
YOM:
1989
Flight number:
FD209
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 13 December 2016, a Beech Aircraft Corporation B200, registered VH-MVL, conducted a medical services flight from Innamincka, South Australia (SA) to Moomba, SA. On board the aircraft were the pilot and two passengers. On arrival at Moomba at about 1250 Central Daylight-saving Time (CDT), the pilot configured the aircraft to join the circuit with flaps set to the approach setting and the propeller speed set at 1900 RPM. They positioned the aircraft at 150–160 kt airspeed to join the downwind leg of the circuit for runway 30, which is a right circuit. The pilot lowered the landing gear on the downwind circuit leg. They reduced power (set 600-700 foot-pounds torque on both engines) to start the final descent on late downwind abeam the runway 30 threshold, in accordance with their standard operating procedures. At about the turn point for the base leg of the circuit, the pilot observed the left engine fire warning activate. The pilot held the aircraft in the right base turn, but paused before conducting the engine fire checklist immediate actions in consideration of the fact that they were only a few minutes from landing and there were no secondary indications of an engine fire. After a momentary pause, the pilot decided to conduct the immediate actions. They retarded the left engine condition lever to the fuel shut-off position, paused again to consider if there was any other evidence of fire, then closed the firewall shutoff valve, activated the fire extinguisher and doubled the right engine power (about 1,400 foot-pounds torque). The pilot continued to fly the aircraft in a continuous turn for the base leg towards the final approach path, but noticed it was getting increasingly difficult to maintain the right turn. They checked the engine instruments and confirmed the left engine was shut down. They adjusted the aileron and rudder trim to assist controlling the aircraft in the right turn. The aircraft became more difficult to control as the right turn and descent continued and the pilot focused on maintaining bank angle, airspeed (fluctuating 100–115 kt) and rate of descent. Due to the pilot’s position in the left seat, they were initially unable to sight the runway when they started the right turn. The aircraft had flown through the extended runway centreline when the pilot sighted the runway to the right of the aircraft. The aircraft was low on the approach and the pilot realised that a sand dune between the aircraft and the runway was a potential obstacle. They increased the right engine power to climb power (2,230 foot-pounds torque) raised the landing gear and retracted the flap to reduce the rate of descent. The aircraft cleared the sand dune and the pilot lowered the landing gear and continued the approach to the runway from a position to the left of the runway centreline. The aircraft landed in the sand to the left of the runway threshold and after a short ground roll spun to the left and came to rest. There were no injuries and the aircraft was substantially damaged.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain involving Beech Aircraft Corporation B200, registered VH-MVL that occurred at Moomba Airport, South Australia on 13 December 2016. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing factors:
- The operator did not modify the aircraft to include a more reliable engine fire detection system in accordance with the manufacturer’s service bulletin, and as subsequently recommended by the Civil Aviation Safety Authority’s airworthiness bulletin. The incorporation of the manufacturer’s modification would have reduced the risk of a false engine fire warning.
- During the approach phase of flight, the pilot shutdown the left engine in response to observing a fire warning, but omitted to feather the propeller. The additional drag caused by the windmilling propeller, combined with the aircraft configuration set for landing while in a right turn, required more thrust than available for the approach.

Other factors that increased risk:
- The advice from the Civil Aviation Safety Authority to the operator, that differences training was acceptable, resulted in the pilot not receiving the operator’s published B200 syllabus of training. The omission of basic handling training on a new aircraft type could result in a pilot not developing the required skilled behaviour to handle the aircraft either near to or in a loss of control situation.

Other findings:
- The pilot met the standard required by the operator in their cyclic training and proficiency program and no knowledge deficiencies associated with handling engine fire warnings were identified.
Final Report:

Crash of a Pacific Aerospace 750XL Falcon 3000 near Tiniroto: 2 killed

Date & Time: Dec 12, 2016 at 0857 LT
Operator:
Registration:
ZK-JPU
Flight Phase:
Flight Type:
Survivors:
No
Site:
MSN:
117
YOM:
2005
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8518
Captain / Total hours on type:
3210.00
Aircraft flight hours:
8028
Circumstances:
At approximately 0500 hrs, 12 December 2016, the pilot of ZK-JPU, arrived at Gisborne Aerodrome. The pilot was accompanied by the operator’s recently employed (trainee) loader driver and already at the hangar was a senior loader driver. The pilot conducted the preflight checks of the aircraft for the day’s agricultural aircraft operations. Earlier that morning the Managing Director of the operator had called the pilot of ZK-JPU. The Managing Director requested that after finishing the first aerial topdressing task at Tauwharetoi Station and prior to the next planned task at Waimaha Station, the pilot complete a task at Pembroke Station. This was because the Managing Director was unwell and unable to undertake the Pembroke Station task as planned. The pilot of ZK-JPU agreed to the additional task. The original work plan for the day was for both loader drivers to attend the first task at Tauwharetoi Station, with the senior loader driver providing oversight for the trainee loader driver. The pilot and the senior loader driver were then to proceed to the second task of the day, while the trainee loader driver was scheduled to return to the aerodrome with the loader truck from the first task. The expectation was for the pilot to go straight from the Tauwharetoi Station task to the Pembroke Station task and then proceed to Waimaha Station. ZK-JPU departed Gisborne Aerodrome at approximately 0515 hrs with the pilot and both loader drivers on board. The aircraft was to operate from a nearby private airstrip where the loader truck was already located, as the task had been commenced the previous week. The aircraft landed at the airstrip at approximately 0530 hrs and the pilot assisted the senior loader driver to get the truck ready, double-checking the calibration of the weigh scales and fuel drain, before commencing the task at approximately 0600 hrs. On the day of the accident another pilot from the same operator, who was operating a similar Pacific Aerospace Ltd 750XL, ZK-XLA, was aerial topdressing an area of Bushy Knoll Station, operating off the Tongataha airstrip. Bushy Knoll Station is to the north of Tauwharetoi Station, alongside the route to the next two tasks scheduled for ZK-JPU at Pembroke and Waimaha Stations. The pilot of ZK-XLA commenced operating at approximately 0555 hrs and completed two to three loads before hearing the pilot of ZK-JPU over the radio at approximately 0615 hrs. The brief conversation that followed consisted of an exchange of greetings and description of locations and intentions. Both pilots then continued with their tasks without further direct communication. On completion of the first task the pilot of ZK-JPU landed at the private airstrip and instructed the senior loader driver to pack up the gear and head back to base. The senior loader driver refuelled the aircraft with 100 litres of fuel, packed up the gear and gave the trainee loader driver the radio which had been used to communicate with the pilot. After a 15 minute break the pilot of ZK-JPU was observed by the senior loader driver getting into the left seat of the aircraft and the trainee loader driver into the right seat. The senior loader driver observed ZK-JPU take off, and then departed the airstrip in the loader truck, to return to the aerodrome. At approximately 0850 the pilot of ZK-XLA received a radio call from the pilot of ZKJPU asking “are you breaking left or right?” followed by the pilot of ZK-JPU stating “I am to your left”. ZK-JPU was then observed by the pilot of ZK-XLA flying behind and to the left of ZK-XLA. The pilot of ZK-XLA advised the pilot of ZK-JPU that he was “sowing the boundary of Bushy Knoll Station […] finishing my run and […] turning right to head back to the airstrip”. Spanning the valley near the boundary of Bushy Knoll Station, near to where the pilot of ZK-XLA was operating were a set of 110 kV high voltage power lines (consisting of six wires termed ‘conductors’, supported by towers). These conductors comprised the two circuits supplying electricity to Gisborne and the East Coast region. The span traverses the valley approximately east-west and the height above terrain at the mid-span of the bottom two conductors (the lowest point of the span) was approximately 200 ft. At 0857 hrs the power supply to Gisborne and the East Coast was interrupted. Finishing the topdressing run, the pilot of ZK-XLA commenced a right climbing turn in order to return to the airstrip and sighted ZK-JPU over his right shoulder. At this point the pilot of ZK-XLA noted that something was trailing from the left wing of ZKJPU. Realising that the item trailing from ZK-JPU’s wing was a wire, the pilot of ZKXLA transmitted “you are trailing wire’’, however no response was received from ZK-JPU. The pilot of ZK-XLA witnessed ZK-JPU continue down the valley, slowly rolling to the left before impacting terrain, approximately 700 m further to the south. A postimpact fire ensued with the pilot of ZK-XLA observing “a lot of black smoke”. The pilot of ZK-XLA immediately commenced circling the accident site and attempted to call the operator via cellphone. Unable to make contact the pilot activated the emergency communications facility on the flight following equipment installed in the aircraft and reported the accident to Gisborne Tower. The accident occurred in daylight at 0857 hrs, approximately 24 NM W of Gisborne Aerodrome, at Latitude: S 38° 44' 30.85" Longitude: E 177° 28' 37.41".
Probable cause:
Conclusions
3.1 The aircraft struck six 110 kV high voltage power lines.
3.2 The pilot likely experienced inattentional blindness, in that the pilot’s attention was likely engaged on the other aircraft and thus the pilot failed to perceive the visual stimuli.
3.3 The pilot was appropriately rated and licensed to conduct the flight.
3.4 Research has shown that striking a wire that the pilot was aware of usually occurred because something changed, such as a last minute change of plan.
3.5 The pilot elected to change the plan at the last minute and detour during the positioning flight to an area where a pilot from the same operator was also conducting aerial topdressing.
3.6 The pilot did not conduct a hazard briefing for the area about to be flown and thus did not afford himself the most accurate and well informed mental model of the area the pilot elected to operate in.
3.7 Several human factors likely influenced the pilot’s decision-making and risk perception leading to the decision to change the original plan and deviate from the minimum heights as stipulated by CAR 91.311 and operators SOPs.
3.8 The safety investigation did not identify any mechanical defects which may have contributed to the accident.
3.9 The accident was not survivable.
Final Report:

Crash of a Britten-Norman BN-2T Islander in Kiunga: 12 killed

Date & Time: Apr 13, 2016 at 1420 LT
Type of aircraft:
Operator:
Registration:
P2-SBC
Survivors:
No
Schedule:
Oksapmin – Kiunga
MSN:
3010
YOM:
1983
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
4705
Captain / Total hours on type:
254.00
Aircraft flight hours:
2407
Aircraft flight cycles:
2886
Circumstances:
On the afternoon of 13 April 2016, a Pilatus Britten Norman Turbine Islander (BN-2T) aircraft, registered P2-SBC, operated by Sunbird Aviation Ltd, departed from Tekin, West Sepik Province for Kiunga, Western Province, as a charter flight under the visual flight rules. On board were the pilot-in-command (PIC) and 11 passengers (eight adults and three children). The aircraft was also carrying vegetables. The pilot reported departing Oksapmin at 13:56. The pilot had flight planned, Kiunga to Oksapmin to Kiunga. However, the evidence revealed that without advising Air Traffic Services, the pilot flew from Oksapmin to Tekin. On departure from Tekin the pilot transmitted departure details to ATS, stating departure from Oksapmin. The recorded High Frequency radio transmissions were significantly affected by static and hash. The weather at Kiunga was reported to be fine. As the aircraft entered the Kiunga circuit area, the pilot cancelled SARWATCH with Air Traffic Services (ATS). The pilot did not report an emergency to indicate a safety concern. Witnesses reported that during its final approach, the aircraft suddenly pitched up almost to the vertical, the right wing dropped, and the aircraft rolled inverted and rapidly “fell to the ground”. It impacted the terrain about 1,200 metres west of the threshold of runway 07. The impact was vertical, with almost no forward motion. The aircraft was destroyed, and all occupants were fatally injured.
Probable cause:
The aircraft’s centre of gravity was significantly aft of the aft limit. When landing flap was set, full nose-down elevator and elevator trim was likely to have had no effect in lowering the nose of the aircraft. Unless the flaps had been retracted immediately, the nose-up pitch may also have resulted in tail plane stall, exacerbating the pitch up. The wings stalled, followed immediately by the right wing dropping. Recovery from the stall at such a low height was not considered possible.
Other factors:
Other factors is used for safety deficiencies or concerns that are identified during the course of the investigation, that while not causal to the accident, nevertheless should be addressed with the
aim of accident and serious incident prevention, and the safety of the travelling public.
a) Following the reweighing of SBC, the operator did not make adjustments to account for the shift of the moment arm as a result of the reweighing. Specifically, a reduction of allowable maximum weight in the baggage compartment.
b) The pilot, although signing the flight manifest on previous flights attesting that the aircraft was loaded within c of g limits, had not computed the c of g. No documentation was available to confirm that the pilot had computed the c of g for the accident flight, or any recent flights.
c) All of the High Frequency radio transmissions between Air Traffic Services and SBC were significantly affected by static interference and a lot of hash, making reception difficult, and many transmissions unclear and unreadable. This is a safety concern to be addressed to ensure that vital operational radio transmissions are not missed for the safety of aircraft operations, and the travelling public.
Final Report:

Crash of a Cessna 208 Caravan I in Whitsunday Island

Date & Time: Jan 28, 2016 at 1518 LT
Type of aircraft:
Operator:
Registration:
VH-WTY
Survivors:
Yes
Schedule:
Hamilton Island - Whitsunday Island
MSN:
208-0522
YOM:
2010
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1350
Captain / Total hours on type:
230.00
Aircraft flight hours:
1510
Circumstances:
On 28 January 2016 the pilot of a Cessna Aircraft Company Caravan 208 amphibian aircraft, registered VH-WTY (WTY) was conducting a series of charter flights in the Whitsunday region of Queensland. The pilot was conducting his third flight of the day when the aircraft departed Hamilton Island Airport at about 1415 Eastern Standard Time with 10 passengers on board. The tour included a scenic flight over the Great Barrier Reef for about 50 minutes before heading to Chance Bay, on the south-east tip of Whitsunday Island, about 11 km north east of Hamilton Island Airport. Following a water landing at Chance Bay, the group was to spend 90 minutes at the beach before a short flight back to Hamilton Island. The tour was originally planned to include a landing at Whitehaven Beach, however wind conditions at the time required the water landing be altered to Chance Bay. Radar surveillance data showed WTY approach Whitsunday Island from the north and conduct an orbit about 2 km north of Whitehaven Beach at about 1510, before heading toward Whitehaven Beach. WTY flew over the southern end of Whitehaven Beach and the strip of land that separates it from Chance Bay. At about 1515, after crossing Chance Bay beach in a southerly direction, WTY descended below radar surveillance for the remainder of the flight. The pilot advised that he flew WTY over the western end of Chance Bay’s main beach in order to conduct a visual pre-landing check of the bay. The pilot noted the positions of various vessels moored in the bay to determine the best taxi path to the beach. During this fly-over, the pilot also noted the sea state and observed evidence of wind gusts on the water surface. The pilot then initiated a right downwind turn toward the landing area. The approach was from the south with the intent to land in the most suitable location within the designated landing area and then taxi to the beach. The pilot reported setting up for landing at about 50 ft above the water and then delayed the landing in order to fly through an observed wind gust. Passenger video footage indicated that, during the subsequent landing, WTY bounced three times on the surface of the water. After the second bounce, with WTY getting closer to the beach and terrain, the pilot increased engine power and initiated a go-around. The third bounce, which occurred almost immediately after the second, was the most pronounced and resulted in the aircraft rebounding about 30 to 50 ft above the water. While increasing power, the pilot perceived that the torque was indicating red, suggesting an over-torque for the selected propeller configuration. Noticing that the climb performance was less than expected with the flaps at 30˚, the pilot stopped increasing power and reduced the flap to 20˚. As the aircraft climbed straight ahead towards a saddle, climb performance was still below the pilot’s expectations and he assessed that WTY would not clear the terrain. In response, the pilot turned right to avoid the surrounding rising terrain. WTY clipped trees during this turn, before colliding with terrain and coming to rest in dense scrub about 150 m from the eastern end of the main beach, near the top of the ridge. The pilot promptly advised the passengers to exit and move away from the aircraft. Some of the 11 people on board suffered minor injuries but all were able to quickly leave the aircraft. There was no post-impact fire. The aircraft’s fixed emergency beacon self-activated during the collision with terrain and was detected by the Australian Maritime Safety Authority (AMSA), resulting in a search and rescue response being initiated by the Joint Rescue Coordination Centre (JRCC) Australia. The pilot reported also activating his personal locator beacon, however this was not detected by AMSA. In addition, the pilot used the company satellite phone to advise the operator of the occurrence and current status of all on board. At about the same time, several witnesses who were located in Chance Bay made their way to the aircraft before assisting everyone down to the beach. A tourist boat was utilized to transfer the pilot and passengers to Hamilton Island, arriving at about 1600. From there, one passenger was transferred by helicopter to Mackay for further treatment.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain involving amphibian Cessna Aircraft Company C208 Caravan aircraft, registered VH-WTY that occurred at Chance Bay, 11 km north-east of Hamilton Island airport, Queensland, on 28 January 2016. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing factors:
- The aircraft's initial touches with water were past the nominated decision point and beyond the northern boundary of the ALA, which reduced the safety margins available for a successful water landing or go-around.
- The pilot initiated a go-around without using all available power and the optimal speed, turned towards higher terrain and placed the aircraft in a down-wind situation, which ultimately resulted in the collision with terrain.
Other findings:
- The aircraft was equipped with lap-sash seatbelts, which have been demonstrated to reduce injury, and the use of emergency beacons and satellite phone facilitated a timely response to the accident.
Final Report:

Crash of a Cessna 550 Citation Bravo in Lismore

Date & Time: Sep 25, 2015 at 1300 LT
Type of aircraft:
Operator:
Registration:
VH-FGK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lismore - Baryulgil
MSN:
550-0852
YOM:
1998
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5937
Copilot / Total flying hours:
377
Aircraft flight hours:
2768
Circumstances:
On the morning of 25 September 2015, the captain and copilot of a Cessna 550 aircraft (Citation Bravo), registered VH-FGK, prepared to conduct a private flight from Lismore Airport to Baryulgil, about 40 NM south-west of Lismore, New South Wales. The aircraft had been parked at the northern end of the airport overnight, with engine covers and control locks on. After arriving at the airport, the flight crew conducted a pre-flight inspection, with no abnormalities identified. They then commenced the normal pre-start checks, which included the disengagement of the flight control locks. The crew elected to use runway 15 for take-off, and used the Cessna simplified take-off performance criteria (see Take-off performance simplified criteria) to determine the thrust settings and take-off reference speeds. The resultant reference speeds were 105 kt for the decision speed (V1) and 108 kt for the rotation speed (VR). At about 1300 Eastern Standard Time, the flight crew started the engines and performed the associated checks, with all indications normal. The crew reported that they completed the after start checks, and the captain then taxied the aircraft to the holding point for runway 15, less than 200 m from where the aircraft was parked. While stopped at the holding point, the crew completed the taxi and pre-take-off checks, the copilot broadcast the standard calls on the common traffic advisory frequency, and the captain communicated with air traffic control (ATC). The captain taxied the aircraft onto the runway, and turned left onto the runway centreline to commence the take-off run from the intersection. While rolling along the runway, the captain advanced the thrust levers to the approximate take-off setting. The captain then called ‘set thrust’, and the copilot set the thrust levers to the more precise position needed to achieve the planned engine thrust for the take-off. As the aircraft accelerated, the copilot called ‘80 knots’ and crosschecked the two airspeed indicators were in agreement and reading 80 kt. The copilot called ‘V1’ and the captain moved their hands from the thrust levers to the control column in accordance with the operator’s normal procedure. A few seconds later, the copilot called ‘rotate’ and the captain initiated a normal rotate action on the control column. The crew reported that the aircraft did not rotate and that they did not feel any indication that the aircraft would lift off. The copilot looked outside and did not detect any change in the aircraft’s attitude as would normally occur at that stage. The captain stated to the copilot that the aircraft would not rotate, and pulled back harder on the control column. The copilot looked across and saw the captain had pulled the control column firmly into their stomach. Although the aircraft’s speed was then about 112 kt, and above VR, the crew did not detect any movement of the attitude director indicator or the nose wheel lifting off the ground, so the captain rejected the take-off; applied full brakes, and set the thrust levers to idle and then into reverse thrust. The aircraft continued to the end of the sealed runway and onto the grass in the runway end safety area (RESA), coming to rest slightly left of the extended centreline, about 100 m beyond the end of the runway. The aircraft sustained substantial damage and the flight crew, who were the only occupants of the aircraft, were uninjured. The nose landing gear separated from the aircraft during the overrun, and there was significant structural damage to the fuselage and wings. The right wheel tyre had deflated due to an apparent wheel lockup and flat spot, which had progressed to a point that a large hole had been worn in the tyre.
Probable cause:
Contributing factors:
- There was probably residual braking pressure in the wheel brakes during the take-off run.
- The aircraft’s parking brake was probably applied while at the holding point and not disengaged before taxing onto the runway for take-off.
- The Citation aircraft did not have an annunciator light to show that the parking brake is engaged, and the manufacturer’s before take-off checklist did not include a check to ensure the parking brake is disengaged.
- The aircraft experienced a retarded acceleration during the take-off run, and did not rotate as normal when the appropriate rotate speed was reached, resulting in a critical rejected take-off
and a runway overrun.
Final Report:

Crash of a Rockwell 500U Shrike Commander in Badu Island

Date & Time: Mar 8, 2015 at 1230 LT
Operator:
Registration:
VH-WZV
Flight Phase:
Survivors:
Yes
Schedule:
Badu Island - Horn Island
MSN:
500-1656-11
YOM:
1966
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 8 March 2015, the pilot of an Aero Commander 500 aircraft, registered VH-WZV, prepared to conduct a charter flight from Badu Island to Horn Island, Queensland, with five passengers. The aircraft had been refuelled earlier that day at Horn Island, where the pilot conducted fuel drains with no contaminants found. He had operated the aircraft for about 2 hours prior to landing at Badu Island with no abnormal performance or indications. At about 1330 Eastern Standard Time (EST), the pilot started the engines and conducted the standard checks with all indications normal, obtained the relevant clearances from air traffic control, and taxied for a departure from runway 30. As the pilot lined the aircraft up on the runway centreline at the threshold, he performed a pre-take-off safety self-brief and conducted the pre-takeoff checks. He then applied full power, released the brakes and commenced the take-off run. All engine indications were normal during the taxi and commencement of the take-off run. When the airspeed had increased to about 80 kt, the pilot commenced rotation and the nose and main landing gear lifted off the runway. Just as the main landing gear lifted off, the pilot detected a significant loss of power from the left engine. The aircraft yawed to the left, which the pilot counteracted with right rudder. He heard the left engine noise decrease noticeably and the aircraft dropped back onto the runway. The pilot immediately rejected the take-off; reduced the power to idle, and used rudder and brakes to maintain the runway centreline. The pilot initially assessed that there was sufficient runway remaining to stop on but, due to the wet runway surface, the aircraft did not decelerate as quickly as expected and he anticipated that the aircraft would overrun the runway. As there was a steep slope and trees beyond the end of the runway, he steered the aircraft to the right towards more open and level ground. The aircraft departed the runway to the right, collided with a fence and a bush resulting in substantial damage. The pilot and passengers were not injured.
Final Report:

Crash of a Pacific Aerospace PAC 750XL in Taupo Lake

Date & Time: Jan 7, 2015 at 1216 LT
Operator:
Registration:
ZK-SDT
Flight Phase:
Survivors:
Yes
Schedule:
Taupo - Taupo
MSN:
122
YOM:
2005
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
588
Captain / Total hours on type:
14.00
Circumstances:
On 7 January 2015 a Pacific Aerospace Limited 750XL aeroplane was being used for tandem parachuting (or ‘skydiving’) operations at Taupō aerodrome. During the climb on the fourth flight of the day, the Pratt & Whitney Canada PT6A-34 engine failed suddenly. The 12 parachutists and the pilot baled out of the aeroplane and landed without serious injury. The aeroplane crashed into Lake Taupō and was destroyed.
Probable cause:
The following findings were identified:
- The first compressor turbine blade failed after a fatigue crack, which had begun at the trailing edge, propagated towards the leading edge. The blade finally fractured in tensile overload. The separated blade fragment caused other blades to fracture and the engine to stop.
- The fatigue crack in the trailing edge of the blade was likely initiated by the trailing edge radius having been below the specification for a new blade.
- The P&WC Repair Requirement Document 725009-SRR-001, at the time the blades were overhauled, had generic requirements for trailing edge thickness inspections but did not specify a minimum measurement for the trailing edge radius.
- The higher engine power settings used by the operator since August 2014 were within the flight manual limits. Therefore it was unlikely that the operator’s engine handling policy contributed to the engine failure.
- The operator had maintained the engine in accordance with an approved, alternative maintenance programme, but the registration of the engine into that programme had not been completed. The administrative oversight did not affect the reliability of the engine or contribute to the blade failure.
- It was likely that the maintenance provider had not followed fully the engine manufacturer’s recommended procedure for inspecting the compressor turbine blades. It could not be determined whether the crack might have been present, and potentially detectable, at the most recent borescope inspection.
- The operator had not equipped its pilots with flotation devices to cover the possibility of a ditching or an emergency bale-out over or near water.
- The pilot had demonstrated that he was competent and he had the required ratings. However, it was likely that the operator’s training of the pilot in emergency procedures was inadequate. This contributed to the pilot making a hasty exit from the aeroplane that jeopardized others.
Final Report: