Country
code

New South Wales

Crash of a Partenavia P.68B in Wagga Wagga: 2 killed

Date & Time: Jul 20, 1998 at 1739 LT
Type of aircraft:
Registration:
VH-IXH
Flight Type:
Survivors:
No
Schedule:
Corowa – Albury – Wagga Wagga
MSN:
186
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1014
Captain / Total hours on type:
217.00
Circumstances:
The aircraft operator had been contracted to provide a regular service transporting bank documents, medical pathology samples and items of general freight between Wagga Wagga, Albury and Corowa. On the day of the accident a passenger was accompanying the pilot for the day's flying. The pilot commenced the flight from Corowa to Albury under the Visual Flight Rules, flying approximately 500 ft above ground level. At Albury he obtained the latest aerodrome weather report for Wagga Wagga, which indicated that there was scattered cloud at 300 ft above ground level, broken cloud at 600 ft above ground level, visibility restricted to 2,000 m in light rain and a sea-level barometric pressure (QNH) of 1008 hPa. At 1715 Eastern Standard Time (EST) the aircraft departed Albury for Wagga Wagga under the Instrument Flight Rules. The pilot contacted the Melbourne en-route controller at 1728 and reported that he was maintaining 5,000 ft. Although the aircraft was operating outside controlled airspace, the en-route controller did have a radar surveillance capability and was providing the pilot with a flight information service. However, no return was recorded from the aircraft's transponder and at 1732 the pilot reported that he was transferring to the Wagga Wagga Mandatory Broadcast Zone frequency. This was the pilot's last contact with the controller. Although air traffic services do not monitor or record the Wagga Wagga Mandatory Broadcast Zone frequency, transmissions made on this frequency are recorded by AVDATA for the purpose of calculating aircraft landing charges. This information was reviewed following the accident. The pilot broadcast his position inbound to the aerodrome on the mandatory broadcast zone frequency and indicated that he was conducting a Global Positioning System (GPS) arrival. He established communication with the pilot of another inbound aircraft and at 9 NM from the aerodrome, broadcast his position as he descended through 2,900 ft. Approximately 1 minute and 20 seconds later, the pilot advised that he was passing 2,000 ft but immediately corrected this to state that he was maintaining 2,000 ft. He also stated that it was "getting pretty gloomy" and that according to the latest weather report he should be visual at the procedure's minimum descent altitude. The aircraft would have been approximately 6 NM from the aerodrome at this time. This was the last transmission heard from the pilot. The resident of a house to the south of Gregadoo Hill sighted the aircraft a short time before the accident. He was standing outside his house and stated that the aircraft was visible as it passed directly overhead at what appeared to be an unusually low height. The aircraft then disappeared into cloud that was obscuring Gregadoo Hill, approximately 350 m from where he was standing. Moments later he heard the sound of an impact followed almost immediately by a red flash of light. The noise from the engines appeared to be normal up until the sound of the impact. The aircraft had collided with steeply rising terrain on the southern face of Gregadoo Hill, approximately 40 ft below the crest. The hill is 4 NM from the aerodrome and is marked on instrument approach charts as a spot height elevation of 1,281 ft. The estimated time of the accident was 1739. The pilot and passenger sustained fatal injuries.
Probable cause:
The pilot had received an accurate appreciation of the weather conditions in the vicinity of Wagga Wagga prior to departing Albury. At that stage it would have been apparent that low cloud and poor visibility were likely to affect the aircraft's arrival. Under such conditions it would not have been possible to land from the GPS arrival procedure. As the reported cloud base and visibility were both below the minimum criteria, it is difficult to rationalise the pilot's transmission that, according to the latest weather report, he would be visual at the minimum descent altitude. This statement suggests that the pilot had already made the decision to continue his descent below the minimum altitude for the procedure and to attempt to establish visual reference for landing. Based on the report of broken low cloud in the vicinity of the aerodrome, the pilot would have needed to descend to 1,324 ft above mean sea level to establish the aircraft clear of cloud. This is within 50 ft of the last altitude recorded on the GPS receiver. Due to the difference between the actual and forecast QNH, the left altimeter would over-read by approximately 150 ft. At the time of the occurrence an otherwise correctly functioning instrument would have indicated an altitude of approximately 1,400 ft. The pilot had probably set the right altimeter to the local QNH prior to departing Albury. As this setting also corresponded to the actual QNH at Wagga Wagga, that instrument would have provided the more accurate indication of the aircraft's operating altitude. However, because of its location on the co-pilot's instrument panel, it is unlikely that the pilot would have included that altimeter in his basic instrument scan. It was not possible to assess the extent to which illicit drugs may have influenced the pilot's performance during the flight and affected his ability to safely operate the aircraft.
The following factors were identified:
- The pilot was operating the aircraft in instrument meteorological conditions below the approved minimum descent altitude.
- Low cloud was covering Gregadoo Hill at the time of the accident.
Final Report:

Crash of a Lockheed PV-1 Ventura in Richmond

Date & Time: Nov 18, 1996 at 1335 LT
Type of aircraft:
Operator:
Registration:
VH-SFF
Flight Type:
Survivors:
Yes
Schedule:
Richmond - Richmond
MSN:
5378
YOM:
1943
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11444
Captain / Total hours on type:
25.00
Circumstances:
The aircraft was approaching to land after completing a handling display during an Open Day at RAAF Richmond. At an altitude of about 800 feet, on the base leg for runway 28, both engines stopped simultaneously and without warning. As there was insufficient altitude to reach the field for a power off landing, the flaps and landing gear were retracted and a successful forced landing carried out into a cleared field short of the airfield. The crew evacuated the aircraft without injury.
Probable cause:
A subsequent investigation failed to positively determine the cause of the simultaneous stoppage of both engines. A large quantity of fuel remained in the tanks and no defects were found with either of the engine fuel systems. The engine ignition systems were tested and functioned normally after the accident. The design of this aircraft, as with other ex-military multi-reciprocating engine types, includes a master ignition switch. The switch is guarded, and when turned off results in the termination of ignition to all engines simultaneously. The switch was removed from the aircraft after the accident and subjected to extensive testing, including vibration tests, but could not be faulted. It was noted however that ignition isolation resulted with only a small movement of the switch from the ON position. The most likely reason for the sudden stoppage of both engines was movement of the master ignition switch from the ON position, possibly as the result of vibration or by a crew member inadvertently bumping the switch prior to landing.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Point Lookout: 1 killed

Date & Time: Nov 15, 1996 at 1300 LT
Type of aircraft:
Operator:
Registration:
VH-IDI
Flight Phase:
Survivors:
No
Schedule:
Kotupna - Kotupna
MSN:
1535
YOM:
1963
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1400
Captain / Total hours on type:
200.00
Circumstances:
On the morning of the accident, the pilot and the loader-driver left Armidale in the aircraft between 0715 and 0730 and flew to the property "KOTUPNA". The task required the aircraft to operate from an agricultural strip 4,400 ft above mean sea level. Superphosphate spreading operations commenced between 0745 and 0800 and continued for approximately 1.5 hours after which the pilot and driver refuelled the aircraft and had a break. The pilot remarked to the driver that the aircraft was going very well and requested him to load a tonne of superphosphate. Operations resumed for about 1.5 hours and then ceased again whilst the aircraft was refuelled. After refuelling, the driver and the pilot had lunch and a break for about half an hour. The pilot again advised the loader driver that he would take a tonne, as the aircraft was performing well. After warming up the engine, the pilot made a normal take-off in a northeasterly direction and banked to the left to head southwest to the treatment area. The driver observed that the aircraft was lower and closer into the strip than had been the normal route to the treatment area. The aircraft did not seem to be climbing sufficiently to pass over the hill in front of it. The aircraft was then seen to be in a climbing left turn, toward the driver with superphosphate dumping from it. The aircraft's left wingtip contacted the ground after which the aircraft cartwheeled and came to rest 200-300 meters from the superphosphate dump. The driver ran down to the aircraft and found the pilot still strapped in the seat with no apparent sign of life. He moved the pilot clear of the aircraft in case of fire and then summoned help.
Probable cause:
The following factors were reported:
- Wind conditions, which were conducive to windshear and turbulence, were present in the area.
- The aircraft was climbing at near maximum weight.
- The aircraft was climbing into rising ground.
- The aircraft was operating at a high-density altitude, which would have placed it near its performance limit.
- Control of the aircraft was lost with insufficient height to effect recovery.
Final Report:

Crash of a Fletcher FU-24-A4 near Dunedoo: 1 killed

Date & Time: Oct 30, 1996 at 1000 LT
Type of aircraft:
Operator:
Registration:
VH-BBG
Flight Phase:
Survivors:
No
Schedule:
Dunedoo - Dunedoo
MSN:
141
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7200
Captain / Total hours on type:
28.00
Circumstances:
The pilot had arrived at the property to commence spraying operations on the day before the accident, and had been provided with a map of the area by the property owner. In addition, the property owner briefed the pilot on the location of relevant powerlines and other obstructions. However, the pilot did not carry out any spraying on that day, but instead flew the aircraft to Scone, in order to have a minor engine problem rectified. He then flew to Mudgee where the aircraft remained overnight. The pilot returned to the area the next morning, arriving on site at about 0645 ESuT. After spraying approximately 175 acres on an adjoining farm, he commenced an aerial inspection of the next property to be treated, but declined an offer by the property owner to accompany him in the aircraft so the property boundaries and powerlines could be pointed out. The aircraft was seen to make three passes over the area before it descended in an easterly direction, toward a crop of barley. A gentle rise, which included a dam bank located at the corner of the crop, had to be negotiated in order for the pilot to position the aircraft at the correct operating height for the swath run. A spurline, suspended over the crop and running in a northerly direction, was located a further 40 m beyond the dam. A witness reported that the aircraft had appeared to be maintaining level flight, and had commenced spraying, when it struck the spurline, then impacted heavily with the ground and overturned, fatally injuring the pilot. The weather in the area at the time of the accident was reported as fine, with light winds. The aircraft struck a three-wire spurline which ran in a northerly direction over the crop, at right angles to its flight path. The line spanned 165 m from the main powerline to the first spurline pole, located about 100 m from a house and to the left of the flight path. A number of large trees nearer to the house provided a backdrop to the spurline pole. A strainer wire stemming from the main powerline was positioned some 92 m further on in the direction of the intended flight path. It was about 10 m in length and ran parallel to the spurline. The strainer wire passed over a road and was attached to a support pole located one metre from the edge of the barley crop. The pilot had commenced the first swathe run by flying in an easterly direction, towards distant rising ground which was cloaked in shadow, whilst the powerline in the foreground was set against this backdrop.
Probable cause:
The following factors were reported:
1. The pilot had limited recent flying experience.
2. The pilot had limited experience on the aircraft type, particularly with regard to low-level spraying operations, prior to the accident.
3. The performance of the pilot may have been impared by the effects of a medical condition he was suffering from.
4. The location of the spurline was difficult to see and may have been confused with an apparent powerline, further along the intended flight path.
5. The aircraft was not fitted with any form of wire deflector or cutter.
6. The aircraft provided limited structural rollover protection for the pilot during the accident sequence.
Final Report:

Crash of a Swearingen SA227AC Metro III in Tamworth: 2 killed

Date & Time: Sep 16, 1995 at 1957 LT
Type of aircraft:
Operator:
Registration:
VH-NEJ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tamworth - Tamworth
MSN:
AC-629B
YOM:
1985
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4132
Captain / Total hours on type:
1393.00
Copilot / Total flying hours:
1317
Copilot / Total hours on type:
1
Aircraft flight hours:
15105
Circumstances:
Two company pilots were undergoing first officer Metro III type-conversion flying training. Both had completed Metro III ground school training during the week before the accident. A company check-and-training pilot was to conduct the type conversions. This was his first duty period after 2 weeks leave. Before commencing leave, he had discussed the training with the chief pilot. This discussion concerned the general requirements for a co-pilot conversion course compared to a command pilot course but did not address specific sequences or techniques. The three pilots met at the airport at about 1530 EST on 16 September 1995. During the next 2 hours and 30 minutes approximately, the check-and-training pilot instructed the trainees in daily and pre-flight inspections, emergency equipment and procedures, and cockpit procedures and drills (including the actions to be completed in the event of an engine failure), as they related to the aircraft type. The briefing did not include detailed discussion of aircraft handling following engine failure on takeoff. The group began a meal break at 1800 and returned to the aircraft at about 1830 to begin the flying exercise. The check-and-training pilot was pilot in command for the flight and occupied the left cockpit seat. One trainee occupied the right (co-pilot) cockpit seat while the other probably occupied the front row passenger seat on the left side. This person had the use of a set of head-phones to listen to cockpit talk and radio calls. The aircraft departed Tamworth at 1852, some 40 minutes after last light. Witnesses described the night as very dark, with no moon. Under these conditions, the Tamworth city lighting, which extended to the east from about 2 km beyond the end of runway 12, was the only significant visual feature in the area. The co-pilot performed the takeoff, his first in the Metro III. For about the next 30 minutes, he completed various aircraft handling exercises including climbing, descending, turning (including steep turns), and engine handling. No asymmetric flight exercises were conducted. The check-and-training pilot then talked the co-pilot through an ILS approach to runway 30R with an overshoot and landing on runway 12L. The landing time was 1940. The aircraft had functioned normally throughout the flight. After clearing the runway, the aircraft held on a taxiway for 6 minutes, with engines running. During this period, the crew discussed the next flight which was to be flown by the same co-pilot. The check-and-training pilot stated that he was going to give the co-pilot a V1 cut. The co-pilot objected and then questioned the legality of night V1 cuts. The check-and-training pilot replied that the procedure was now legal because the company operations manual had been changed. The co-pilot made a further objection. The check-and-training pilot then said that they would continue for a Tamworth runway 30R VOR/DME approach and asked the co-pilot to brief him on this approach. The crew discussed the approach and the check-and-training pilot then requested taxi clearance. The aircraft was subsequently cleared to operate within a 15-NM radius of Tamworth below 5,000 ft. The crew then briefed for the runway 12L VOR/DME approach. The plan was to reconfigure the aircraft for normal two-engine operations after the V1 cut and then complete the approach. The crew completed the after-start checks, the taxi checks, and then the pre-take-off checks. The checks included the co-pilot calling for one-quarter flap and the check-and-training pilot responding that one-quarter flap had been selected. The crew briefed the take-off speeds as V1 = 100 kts, VR = 102 kts, V2 = 109 kts, and Vyse = 125 kts for the aircraft weight of 5,600 kg. Take-off torque was calculated as 88% and watermethanol injection was not required. The aircraft commenced the take-off roll at 1957.05. About 25 seconds after brakes release, the check-and-training pilot called 'V1', and less than 1 second later, 'rotate'. The aircraft became airborne at 1957.32. One second later, the check-and-training pilot reminded the co-pilot that the aircraft attitude should be 'just 10 degrees nose up'. After a further 3 seconds, the check-and-training pilot retarded the left engine power lever to the flight-idle position. Over the next 4 seconds, the recorded magnetic heading of the aircraft changed from 119 degrees to 129 degrees. The co-pilot and then the check-and-training pilot called that a positive rate of climb was indicated and the landing gear was selected up 15 seconds after the aircraft became airborne. The landing gear warning horn began to sound at approximately the same time. After 19 seconds airborne, and again after 30 seconds, the check-and-training pilot reminded the co-pilot to hold V2. Three seconds later, the check-and-training pilot said that the aircraft was descending. The landing gear warning horn ceased about 1 second later. By this time, the aircraft had gradually yawed left from heading 129 degrees, through the runway heading of 121 degrees, to 107 degrees. After being airborne for 35 seconds, the aircraft struck a tree approximately 350 m beyond, and 210 m left of, the upwind end of runway 12L. It then rolled rapidly left, severed power lines and struck other trees before colliding with the ground in an inverted attitude and sliding about 70 m. From the control tower, the aerodrome controller saw the aircraft become airborne. As it passed abeam the tower, the controller directed his attention away from the runway. A short time later, all lighting in the tower and on the airport failed and the controller noticed flames from an area to the north-east of the runway 30 threshold. Within about 30 seconds, when the emergency power supply had come on line, the controller attempted to establish radio contact with the aircraft. When no response was received, he initiated call-out of the emergency services.
Probable cause:
The following factors were reported:
1. There was no enabling legislative authority for AIP (OPS) para. 77.
2. CASA oversight, with respect to the company operations manual and specific guidance concerning night asymmetric operations, was inadequate.
3. The company decided to conduct V1 cuts at night during type-conversion training.
4. The check-and-training pilot was assigned a task for which he did not possess adequate experience, knowledge, or skills.
5. The check-and-training pilot gave the co-pilot a night V1 cut, a task which was inappropriate for the co-pilot's level of experience.
6. The performance of the aircraft during the flight was adversely affected by the period the landing gear remained extended after the simulated engine failure was initiated and by the control inputs of the co-pilot.
7. The check-and-training pilot did not recognise that the V1 cut exercise should be terminated and that he should take control of the aircraft.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Cooplacurripa: 1 killed

Date & Time: Dec 19, 1994 at 1940 LT
Type of aircraft:
Operator:
Registration:
VH-BSC
Flight Phase:
Survivors:
No
Schedule:
Cooplacurripa - Cooplacurripa
MSN:
1617
YOM:
1966
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
800
Captain / Total hours on type:
350.00
Circumstances:
The aircraft was operating from an agricultural airstrip 600 feet above mean sea level, spreading superphosphate over moderately steep undulating terrain. The duration of each flight was 6-7 minutes. The accident flight was the seventh and probably intended to be the last for the day. A witness, who was situated under the flight path, reported that the aircraft was tracking east-north-east in what appeared to be normal flight. Her attention was distracted for a few moments and when she next saw the aircraft it was in a near vertical dive with the upper surface of the wings facing her. The aircraft then struck the hillside and burst into flames. Examination of the wreckage did not reveal any pre-existing defect which may have contributed to the accident. Impact marks on the propeller indicated that the engine was operating at impact. The superphosphate load remained in the hopper and the emergency dump system actuating lever was in the closed position. Inspection indicated that the dump system was serviceable prior to impact. Calculations indicated that at the time of the accident the aircraft, although heavily loaded, was operating within the flight manual maximum weight limitation. A light north-easterly wind was observed at the airstrip. However, at the accident site, which was about 250 feet higher, the wind was a moderate west-north-westerly. Sky conditions were clear with a visibility of 30 km. The aircraft probably experienced windshear and turbulence as it encountered a quartering tailwind approaching the ridgeline. The result would have been a reduction in climb performance and it is likely that the pilot attempted to turn the aircraft away from the rising terrain. During the turn it appears that the aircraft stalled and that the pilot was unable to regain control before it struck the ground.
Probable cause:
The reason the pilot did not dump the load when the climb performance was reduced could not be determined.
The following factors were determined to have contributed to the accident:
1. Shifting wind conditions conducive to windshear and turbulence were present in the area.
2. The aircraft was climbing at near to maximum allowable weight.
3. Control of the aircraft was lost with insufficient height available to effect a recovery.
Final Report:

Crash of a Douglas C-47A-20-DK off Sydney

Date & Time: Apr 24, 1994 at 0910 LT
Registration:
VH-EDC
Flight Phase:
Survivors:
Yes
Schedule:
Sydney - Norfolk Island - Lord Howe Island
MSN:
12874
YOM:
1944
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9186
Captain / Total hours on type:
927.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
250
Aircraft flight hours:
40195
Circumstances:
This accident involved a DC-3 aircraft which was owned and operated by South Pacific Airmotive Pty Ltd, who were based at Camden, NSW. It was flown on commercial operations under an Air Operators Certificate held by Groupair, who were based at Moorabbin, Vic. The aircraft had been chartered to convey college students and their band equipment from Sydney to Norfolk Island to participate in Anzac Day celebrations on the island. A flight plan, submitted by the pilot in command, indicated that the aircraft was to proceed from Sydney (Kingsford-Smith) Airport to Norfolk Island, with an intermediate landing at Lord Howe Island to refuel. The flight was to be conducted in accordance with IFR procedures, with a departure time from Sydney of 0900. The aircraft, which was carrying 21 passengers, was crewed by two pilots, a supernumerary pilot and a flight attendant. Preparations for departure were completed shortly before 0900, and the aircraft was cleared to taxi for runway 16 via taxiway Bravo Three. The pilot in command occupied the left control position. The co-pilot was the handling pilot for the departure. The aircraft was cleared for takeoff at 0907:53. The crew subsequently reported to the investigation team that all engine indications were normal during the take-off roll and that the aircraft was flown off the runway at 81 kts. During the initial climb, at approximately 200 ft, with flaps up and the landing gear retracting, the crew heard a series of popping sounds above the engine noise. Almost immediately, the aircraft began to yaw left and at 0909:04 the pilot in command advised the TWR that the aircraft had a problem. The co-pilot determined that the left engine was malfunctioning. The crew subsequently recalled that the aircraft speed at this time had increased to at least 100 kts. The pilot in command, having verified that the left engine was malfunctioning, closed the left throttle and initiated propeller feathering action. During this period, full power (48 inches Hg and 2,700 RPM) was maintained on the right engine. However, the airspeed began to decay. The handling pilot reported that he had attempted to maintain 81 KIAS but was unable to do so. The aircraft diverged to the left of the runway centreline. The co-pilot and the supernumerary pilot subsequently reported that almost full right aileron had been used to control the aircraft. They could not recall the skid-ball indication. The copilot reported that he had full right rudder or near full right rudder applied. When he first became aware of the engine malfunction, the pilot in command assessed that, although a landing back on the runway may have been possible, the aircraft was capable of climbing safely on one engine. However, when he determined that the aircraft was not climbing, and that the airspeed had reduced below 81 kts, the pilot in command took control, and at 0909:38 advised the TWR that he was ditching the aircraft. He manoeuvred the aircraft as close as possible to the southern end of the partially constructed runway 16L. The aircraft was ditched approximately 46 seconds after the pilot in command first advised the TWR of the problem. The four crew and 21 passengers successfully evacuated the aircraft before it sank. They were taken on board pleasure craft and transferred to shore. After initial assessment, they were transported to various hospitals. All were discharged by 1430 that afternoon, with the exception of the flight attendant, who had suffered serious injuries.
Probable cause:
The following factors were considered significant in the accident sequence.
1. Compliance with the correct performance charts would have precluded the flight.
2. Clear and unambiguous presentation of CAA EROPs documentation should have precluded the flight.
3. The aircraft weight at takeoff exceeded the MTOW, the extent of which was unknown to the crew.
4. An engine malfunction and resultant loss of performance occurred soon after takeoff.
5. The operations manual take-off safety speed used by the crew was inappropriate for the overloaded condition of the aircraft.
6. The available single-engine aircraft performance was degraded when the co-pilot mishandled the aircraft controls.
7. The pilot in command delayed taking over control of the aircraft until the only remaining option was to conduct a controlled ditching.
8. There were organisational deficiencies in the management and operation of the DC-3 involving both Groupair and SPA.
9. There were organisational deficiencies in the safety regulation of both Groupair and SPA by the CAA district offices at Moorabbin and Bankstown.
10. There were organisational deficiencies relating to safety regulation of EROPS by the CAA.
Final Report:

Crash of a Swearingen SA226AT Merlin IVA in Tamworth: 1 killed

Date & Time: Mar 9, 1994 at 1734 LT
Operator:
Registration:
VH-SWP
Flight Type:
Survivors:
No
Schedule:
Inverell – Glen Innes – Armidale – Tamworth – Sydney
MSN:
AT-033
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2782
Captain / Total hours on type:
335.00
Circumstances:
VH-SWP was operating on a standard company flight plan for the route Bankstown-Tamworth-Armidale-Glen Innes-Inverell and return, and the flight plan indicated the flight would be conducted in accordance with IFR procedures. The classification of the flight was shown as non-scheduled commercial air transport although the aircraft was operating to a company schedule, and departure and flight times for each route segment were indicated on the flight plan. The aircraft departed Bankstown at about 0640 and proceeded as planned to Inverell where the pilot rested until his departure that afternoon for the return journey. The schedule required an Armidale departure at 1721. At 1723 the pilot reported to Sydney Flight Service that he was departing Armidale for Tamworth. The planned time for the flight was 17 minutes. Although the flight-planned altitude for this sector was 6,000 ft, the pilot was unable to climb immediately because a slower aircraft, which had departed Armidale for Tamworth two minutes earlier, was climbing to that altitude. In addition, there was opposite direction traffic at 7,000 ft. The next most suitable altitude was 8,000 ft, but separation from the other two aircraft, which were also IFR, had to be established by the pilot before further climb was possible. The published IFR lowest safe altitude for the route was 5,400 ft. The pilot subsequently elected to remain at 4,500 ft in visual meteorological conditions (VMC) and at 1727 requested an airways clearance from Tamworth Tower. A clearance was issued by ATC to the pilot to track direct to Tamworth at 4,500 ft visually. At about 1732 the pilot requested a descent clearance. He was cleared to make a visual approach with a clearance limit of 5 NM by distance measuring equipment (DME) from Tamworth, and was requested to report at 8 DME from Tamworth. The pilot acknowledged the instructions and reported leaving 4,500 ft on descent. Transmissions from ATC to the pilot less than two minutes later were not answered. The aircraft was not being monitored on radar by ATC, nor was this a requirement. At about 1740, reports were received by the police and ATC of an explosion and possible aircraft accident near the mountain range 8 NM north-east of Tamworth Airport. The aircraft wreckage was discovered at about 2115 by searchers on the mountain range.Soon after the aircraft was reported missing, a search aircraft pilot, who had extensive local flying experience, reported to ATC that the top of the range (where the accident occurred) was obscured by cloud, and that there was very low cloud in the valley nearby.
Probable cause:
The following findings were reported:
- The pilot was making a visual approach in weather conditions unsuitable for such an approach.
- The pilot had not flown this route before.
- The aircraft was flown below the lowest safe altitude in conditions of poor visibility.

Crash of a Rockwell Grand Commander 690 off Sydney: 1 killed

Date & Time: Jan 14, 1994 at 0114 LT
Registration:
VH-BSS
Flight Type:
Survivors:
No
Schedule:
Canberra - Sydney
MSN:
690-11044
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1800
Captain / Total hours on type:
50.00
Aircraft flight hours:
7975
Circumstances:
On 14 January 1994 at 0114, Aero Commander 690 aircraft VH-BSS struck the sea while being radar vectored to intercept the Instrument Landing System approach to runway 34 at Sydney (Kingsford-Smith) Airport, NSW. The last recorded position of the aircraft was about 10 miles to the south-east of the airport. At the time of the accident the aircraft was being operated as a cargo charter flight from Canberra to Sydney in accordance with the Instrument Flight Rules. The body of the pilot who was the sole occupant of the aircraft was never recovered. Although wreckage identified as part of the aircraft was located on the seabed shortly after the accident, salvage action was not initially undertaken. This decision was taken after consideration of the known circumstances of the occurrence and of the costs of salvage versus the potential safety benefit that might be gained from examination of the wreckage. About 18 months after the accident, the wing and tail sections of the aircraft were recovered from the sea by fishermen. As a result, a detailed examination of that wreckage was carried out to assess the validity of the Bureau’s original analysis that the airworthiness of the aircraft was unlikely to have been a factor in this accident. No evidence was found of any defect which may have affected the normal operation of the aircraft. The aircraft descended below the altitude it had been cleared to by air traffic control. From the evidence available it was determined that the circumstances of this accident were consistent with controlled flight into the sea.
Probable cause:
Findings
1. The pilot held a valid pilot licence, endorsed for Aero Commander 690 aircraft.
2. The pilot held a valid multi-engine command instrument rating.
3. There was no evidence found to indicate that the performance of the pilot was adversely affected by any physiological or psychological condition.
4. The aircraft was airworthy for the intended flight, despite the existence of minor anomalies in maintenance and serviceability of aircraft systems.
5. The aircraft carried fuel sufficient for the flight.
6. The weight and balance of the aircraft were estimated to have been within the normal limits.
7. Recorded radio communications relevant to the operation of the aircraft were normal.
8. Relevant ground-based aids to navigation were serviceable.
9. At the time of impact the aircraft was capable of normal flight.
10. The aircraft was fitted with an altitude alerting system.
11. The aircraft was not fitted with a ground proximity warning system.
12. The aircraft was equipped with a transponder which provided aircraft altitude information to be displayed on Air Traffic Control radar equipment.
3.2 Significant factors
1. The pilot was relatively inexperienced in single-pilot Instrument Flight Rules operations on the type of aircraft being flown.
2. The aircraft was being descended over the sea in dark-night conditions.
3. The workload of the pilot was significantly increased by his adoption of a steep descent profile at high speed, during a phase of flight which required multiple tasks to be completed in a limited time prior to landing. Radio communications with another company aircraft during that critical phase of flight added to that workload.
4. The pilot probably lost awareness of the vertical position of the aircraft as a result of distraction by other tasks.
5. The aircraft was inadvertently descended below the altitude authorized by Air Traffic Control.
6. The secondary surveillance radar system in operation at the time provided an aircraft altitude readout which was only updated on every sixth sweep of the radar display.
7. The approach controller did not notice a gross change of aircraft altitude shortly after a normal radio communication with the pilot.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Young: 7 killed

Date & Time: Jun 11, 1993 at 1918 LT
Registration:
VH-NDU
Survivors:
No
Schedule:
Sydney – Cowra – Young – Cootamundra
MSN:
31-8152083
YOM:
1981
Flight number:
OB301
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
1822
Captain / Total hours on type:
337.00
Copilot / Total flying hours:
954
Copilot / Total hours on type:
43
Aircraft flight hours:
3936
Circumstances:
At about 1500 hours EST, 11 June 1993, a standard company flight plan held by the CAA at the Melbourne flight briefing facility was activated. The plan indicated that Piper PA-31-350 aircraft VH-NDU would be conducting flight OB 301, a regular public transport service from Sydney (Kingsford Smith) airport to Cootamundra NSW, with intermediate landings at Cowra and Young. The flight was planned to be operated in accordance with IFR procedures, with a scheduled departure time from Sydney of 1720. The aircraft was to be crewed by two pilots. Prior to departure, the company scheduled a second aircraft to operate the Sydney–Cowra sector. Consequently, VH-NDU was required to land only at Young and Cootamundra. At that time of the year, the 1720 departure time meant that the flight would be conducted entirely at night. VH-NDU departed Sydney at 1738 carrying five passengers, with a fuel endurance of about 253 minutes. The pilot-in-command occupied the left cockpit seat. The aircraft initially tracked via the direct Sydney to Cowra route and climbed to a cruising altitude of 8,000 feet. At 1801 the pilot reported to Sydney FIS that the aircraft was now tracking direct to Young, and would report at Riley, an en route reporting point located 62 NM from Young on the Katoomba– Young track. FIS advised the area QNH was 1003 hPa. At 1814 the pilot reported the aircraft was at Riley and estimated arrival at Young at 1835. By 1820 the pilot had reported on descent to Young, with in-flight conditions of cloud and heavy rain. Recorded radar data later showed that the aircraft passed 13.5 NM to the south-east of Riley, south of the direct Katoomba–Young track. At about 18.5 NM north-east of Rugby, the aircraft turned right and initially tracked about 280° before turning left to track direct to Young. When queried by FIS at 1836, the pilot amended the estimate for his arrival at Young to 1838. At 1842, after prompting from FIS, the pilot reported at Young that he was commencing an NDB approach, and would call again on the hour or in the circuit. Shortly after 1845 witnesses at Young aerodrome saw the lights of an aircraft, which they believed to be VH-NDU, pass low overhead after approaching from the east. Some minutes later the same aircraft was seen to pass over the aerodrome from the opposite direction and appear to climb away towards the east. On both occasions the runway and aerodrome lights were not illuminated, although the aerodrome was equipped with PAL and it was the responsibility of the pilot-in-command to activate it. At 1850 FIS advised VH-NDU of the proximity of Cessna 310 aircraft, VH-XMA, which was estimating arrival at Young at 1900. VH-XMA subsequently reported holding in visual conditions at about 8 NM north of Young. The pilot of VH-NDU reported at 1903 that he was on another overshoot at Young, about to commence another approach, and would report again at 1915. FIS provided additional traffic on Piper PA31 aircraft, VH-XML, which was also estimating Young at 1915. At about this time witnesses reported seeing the runway lights illuminate. VH-XMA then proceeded to Young and landed on runway 01 at about 1912. At 1916 VH-NDU reported in the Young circuit area and cancelled SARWATCH. A pilot witness said that the aircraft passed over the northern end of the aerodrome from a westerly direction before turning right and taking up a heading consistent with a right downwind leg for a landing on runway 01. The aircraft was then seen to turn right and pass to the south of the aerodrome before entering what appeared to be a right downwind leg for runway 19. When abeam the aerodrome the aircraft again turned right and overflew the aerodrome to enter a second right downwind leg for runway 01. Another witness thought the aircraft (VH-NDU) was significantly lower than another aircraft approaching from the east (VH-XML). Shortly after VH-NDU turned onto an apparent base leg the navigation lights were lost to sight. Almost immediately a fireball was observed, consistent with the final position of the aircraft (see figure 2). At 1918 the pilot of VH-XMA telephoned the 000 emergency services number and reported the accident to the Goulburn Ambulance Control Centre. By 1920 this information had been relayed to the Young Ambulance Service, the Young Police, and the Young SES. An off-duty Fire Brigade officer, who was waiting at the aerodrome, drove into Young and alerted the Fire Brigade at 1930. The emergency services initially travelled to Young Aerodrome but were unable to gain immediate access to the accident site, which was located on a hill some 2.2 km to the south-south-east of the aerodrome, in an area remote from roads and lighting. Access was finally gained from a road located south of the accident site. An ambulance reached the aircraft wreckage at 1952 and the crew were able to rescue and resuscitate the only survivor, who was critically injured, and transport her to the Young Hospital. She died at Camperdown Children’s Hospital at 0510 the next morning.
Probable cause:
Significant factors
1. The cloudbase in the Young circling area was below the minimum circling altitude, associated with dark night conditions and limited ground lighting.
2. The workload of the pilot-in-command was substantially increased by the effects of aircraft equipment deficiencies, with a possible consequent degrading of his performance as a result of skill fatigue.
3. The instrument approach and landing charts did not provide the flight crew with terrain information adequate for the assessment of obstacle clearance during a circling approach.
4. The Monarch operations manual did not provide the flight crew with guidance or procedures for the safe avoidance of terrain at Young during a night-circling approach.
5. The aircraft descended below the minimum circling altitude without adequate monitoring of obstacle clearance by the crew.
6. The visual cues available to the flight crew were insufficient as a sole source of height judgement.
7. There were organisational deficiencies in the management and operation of RPT services by Monarch.
8. There were organisational deficiencies in the safety regulation of Monarch RPT operations by the CAA.
Final Report: