Country
code

New South Wales

Crash of a Piper PA-61 Aerostar (Ted Smith 601) off Byron Bay: 2 killed

Date & Time: Jan 27, 2004 at 1335 LT
Operator:
Registration:
VH-WRF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Coolangatta - Coolangatta
MSN:
61-0497-128
YOM:
1978
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7127
Captain / Total hours on type:
308.00
Copilot / Total flying hours:
283
Copilot / Total hours on type:
3
Circumstances:
The Ted Smith Aerostar 601 aircraft, registered VH-WRF, departed Coolangatta at 1301 ESuT with a flight instructor and a commercial pilot on board. The aircraft was being operated on a dual training flight in the Byron Bay area, approximately 55 km south-south-east of Coolangatta. The aircraft was operating outside controlled airspace and was not being monitored by air traffic control. The weather in the area was fine with a south-easterly wind at 10 - 12 kts, with scattered cloud in the area with a base of between 2,000 and 2,500 ft. The purpose of the flight was to introduce the commercial pilot, who was undertaking initial multi-engine training, to asymmetric flight. At approximately 1445, the operator advised Australian Search and Rescue that the aircraft had not returned to Coolangatta, and that it was overdue. Recorded radar information by Airservices Australia revealed that the aircraft had disappeared from radar coverage at 1335. Its position at that time was approximately 18 km east-south-east of Cape Byron. Search vessels later recovered items that were identified as being from the aircraft in the vicinity of the last recorded position of the aircraft. Those items included aircraft checklist pages, a blanket, a seat cushion from the cabin, as well as a number of small pieces of cabin insulation material. No item showed any evidence of heat or fire damage. No further trace of the aircraft was found.
Probable cause:
Without the aircraft wreckage or more detailed information regarding the behaviour of the aircraft in the final stages of the flight, there was insufficient information available to allow any conclusion to be drawn about the development of the accident. Many possible explanations exist. The fact that no radio transmission was received from the aircraft around the time radar contact was lost could indicate that the aircraft was involved in a sudden or unexpected event at that time that prevented the crew from operating the radio. The speed regime of the aircraft during the last recorded data points indicated that airframe failure due to aerodynamic overload was unlikely. The nature of the items from the aircraft that were recovered from the ocean surface indicated that the aircraft cabin had been ruptured during the accident sequence.
Final Report:

Crash of a Beechcraft B200C Super King Air in Coffs Harbour

Date & Time: May 15, 2003 at 0833 LT
Operator:
Registration:
VH-AMR
Flight Type:
Survivors:
Yes
Schedule:
Sydney – Coffs Harbour
MSN:
BL-126
YOM:
1985
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18638
Captain / Total hours on type:
460.00
Circumstances:
The aircraft impacted the sea or a reef about 6 km north-east of Coffs Harbour airport. The impact occurred immediately after the pilot initiated a go-around during an instrument approach to runway 21 in Instrument Meteorological Conditions (IMC) that included heavy rain and restricted visibility. Although the aircraft sustained structural damage and the left main gear detached, the aircraft remained airborne. During the initial go-around climb, the aircraft narrowly missed a breakwater and adjacent restaurant at the Coffs Harbour boat harbour. Shortly after, the pilot noticed that the primary attitude indicator had failed, requiring him to refer to the standby instrument to recover from an inadvertent turn. The pilot positioned the aircraft over the sea and held for about 30 minutes before returning to Coffs Harbour and landing the damaged aircraft on runway 21. There were no injuries or any other damage to property and/or the environment because of the accident. The aircraft was on a routine aeromedical flight from Sydney to Coffs Harbour with the pilot, two flight nurses, and a stretcher patient on board. The flight was conducted under instrument flight rules (IFR) in predominantly instrument meteorological conditions (IMC). During the descent, the enroute air traffic controller advised the pilot to expect the runway 21 Global Positioning System (GPS) non-precision approach (NPA). The pilot reported that he reviewed the approach diagram and planned a 3-degree descent profile. He noted the appropriate altitudes, including the correct minimum descent altitude (MDA) of 580 ft, on a reference card. A copy of the approach diagram used by the pilot is at Appendix A. The aerodrome controller advised the pilot of the possibility of a holding pattern due to a preceding IFR aircraft being sequenced for an instrument approach to runway 21. The controller subsequently advised that holding would not be required if the initial approach fix (SCHNC)2 was reached not before 0825. At about 0818, the aerodrome controller advised the pilot of the preceding aircraft that the weather conditions in the area of the final approach were a visibility of 5000 m and an approximate cloud base of 1,000 ft. At 0825 the aerodrome controller cleared the pilot of the King Air to track the aircraft from the initial approach fix to the intermediate fix (SCHNI) and to descend to not below 3,500 ft. The published minimum crossing altitude was 3,600 ft. About one minute later the pilot reported that he was leaving 5,500 ft and was established inbound on the approach. At 0828 the pilot reported approaching the intermediate fix and 3,500 ft. The controller advised that further descent was not available until the preceding aircraft was visible from the tower. At 0829 the controller, having sighted the preceding aircraft, cleared the pilot of the King Air to continue descent to 2,500 ft. The pilot advised the controller that he was 2.2 NM from the final approach fix (SCHNF). At that point an aircraft on a 3-degree approach slope to the threshold would be at about 2,500 ft. The controller then cleared the pilot for the runway 21 GPS approach, effectively a clearance to descend as required. The pilot subsequently explained that he was high on his planned 3-degree descent profile because separation with the preceding aircraft resulted in a late descent clearance. He had hand flown the approach, and although he recalled setting the altitude alerter to the 3,500 ft and 2,500 ft clearance limits, he could not recall setting the 580 ft MDA. He stated that he had not intended to descend below the MDA until he was visual, and that he had started to scan outside the cockpit at about 800 ft altitude in expectation of becoming visual. The pilot recalled levelling the aircraft, but a short time later experienced a 'sinking feeling'. That prompted him to go-around by advancing the propeller and engine power levers, and establishing the aircraft in a nose-up attitude. The passenger in the right front seat reported experiencing a similar 'falling sensation' and observed the pilot's altimeter moving rapidly 'down through 200 ft' before it stopped at about 50 ft. She saw what looked like a beach and exclaimed 'land' about the same time as the pilot applied power. The pilot felt a 'thump' just after he had initiated the go-around. The passenger recalled feeling a 'jolt' as the aircraft began to climb. Witnesses on the northern breakwater of the Coffs Harbour boat harbour observed an aircraft appear out of the heavy rain and mist from the north-east. They reported that it seemed to strike the breakwater wall and then passed over an adjacent restaurant at a very low altitude before it was lost from sight. Wheels from the left landing gear were seen to ricochet into the air and one of the two wheels was seen to fall into the water. The other wheel was found lodged among the rocks of the breakwater.During the go-around the pilot unsuccessfully attempted to raise the landing gear, so he reselected the landing gear selector to the 'down' position. He was unable to retract the wing flaps. It was then that he experienced a strong g-force and realised that he was in a turn. He saw that the primary attitude indicator had 'toppled' and referred to the standby attitude indicator, which showed that the aircraft was in a 70-degree right bank. He rapidly regained control of the aircraft and turned it onto an easterly heading, away from land. The inverter fail light illuminated but the pilot did not recall any associated master warning annunciator. He then selected the number-2 inverter to restore power to the primary attitude indicator, and it commenced to operate normally. The pilot observed that the left main landing gear had separated from the aircraft. He continued to manoeuvre over water while awaiting an improvement in weather conditions that would permit a visual approach. About 4 minutes after the King Air commenced the go-around, the aerodrome controller received a telephone call advising that a person at the Coffs Harbour boat harbour had witnessed an aircraft flying low over the harbour, and that the aircraft had '…hit something and the wheel came off'. The controller contacted the pilot, who confirmed that the aircraft was damaged. The controller declared a distress phase and activated the emergency response services to position for the aircraft's landing. Witnesses reported that the landing was smooth. As the aircraft came to rest on the runway, foam was applied around the aircraft to minimise the likelihood of fire. The occupants exited the aircraft through the main cabin door.
Probable cause:
This occurrence is a CFIT accident resulting from inadvertent descent below the MDA on the final segment of a non-precision approach, fortunately without the catastrophic consequences normally associated with such events. The investigation was unable to conclusively determine why the aircraft descended below the MDA while in IMC, or why the descent continued until CFIT could no longer be avoided. However, the investigation identified a number of factors that influenced, or had the potential to influence, the development of the occurrence.
Final Report:

Crash of an Embraer EMB-110P1 Bandeirante in Cootamundra

Date & Time: Jun 25, 2001 at 1021 LT
Operator:
Registration:
VH-OZG
Survivors:
Yes
Schedule:
Sydney – Griffith
MSN:
110-241
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6850
Captain / Total hours on type:
253.00
Circumstances:
The Embraer EMB-110P1 Bandeirante, VH-OZG, departed from Sydney Kingsford Smith international airport at 0855 on 25 June 2001, on a single-pilot instrument flight rules (IFR) charter flight to Griffith. The nine occupants on board the aircraft included the pilot and eight passengers. At about 0945, while maintaining an altitude of 10,000 ft, the master caution light illuminated. At the same time, the multiple alarm panel ‘GENERATOR 2’ (right generator) warning light also illuminated, indicating that the generator was no longer supplying power to the main electrical bus bar. After resetting the generator and monitoring its output, the pilot was satisfied that it was operating normally. A short time later, the master warning light illuminated again. A number of circuit breakers tripped, accompanied by multiple master alarm panel warnings. The red ‘FIRE’ warning light on the right engine fire extinguisher ‘T’ handle also illuminated, accompanied by the aural fire alarm warning. The pilot reported that after silencing the aural fire alarm, he carried out the engine fire emergency checklist actions. However, he was unable to select the fuel cut-off position with the right fuel condition lever, despite overriding the locking mechanism using his left thumb while attempting to operate the lever with his right hand. He also reported that the propeller lever did not remain in the feathered detent, but moved forward, as if spring-loaded, to an intermediate position. After unsuccessfully attempting to select fuel cut-off with the right fuel condition lever, or feather the right propeller with the propeller lever, the pilot pulled the right ‘T’ handle to discharge the fire bottle. The amber discharge light illuminated and a short time later the fire alarm sounded again. Passengers reported seeing lights illuminated on the multiple alarm panel and heard the sound of a continuous fire alarm in the cockpit. At 0956, the pilot notified air traffic services (ATS) that there was a ‘problem’ with the aircraft, but did not specify the nature of that problem. Almost immediately the pilot transmitted a PAN radio call and advised ATS that there was a fire on board the aircraft. The nearest aerodromes for an emergency landing were not available due to fog, and the pilot decided to divert to Young, which was about 35 NM to the south east of the aircraft’s position at that time. The pilot advised ATS that the fire was extinguished, and that he was diverting the aircraft to Young. Two minutes later, the pilot repeated his advice to ATS stating that a fire in the right engine had been extinguished, and requested emergency services for the aircraft’s arrival at Young. The pilot informed one of the passengers that there was an engine fire warning, and that they would be landing at Young. The passengers subsequently reported seeing flames in the right engine nacelle and white smoke streaming from under the wing. Smoke had also started to enter the cabin in the vicinity of the wing root. The pilot subsequently reported that he had selected the master switch on the air conditioning control panel to the ‘vent’ position, and that he had opened the left direct vision window in an attempt to eliminate smoke from the cabin. When that did not appear to have any effect he closed the direct vision window. The pilot of another aircraft reported to ATS that Young was clear, but there were fog patches to the north. On arrival at Young, however, the pilot of the Bandeirante was unable to land the aircraft because of fog, and advised ATS that he was proceeding to Cootamundra, 27 NM to the south southwest of Young. The crew of an overflying airliner informed ATS that Cootamundra was clear of fog. ATS confirmed that advice by telephoning an aircraft operator at Cootamundra aerodrome. At 1017 thick smoke entered the cabin and the pilot transmitted a MAYDAY. He reported that the aircraft was 9 NM from Cootamundra, and ATS informed him that the aerodrome was clear of fog. The pilot advised that he was flying in visual conditions and that there was a serious fire on board. No further radio transmissions were heard from the aircraft. At 1021, approximately 25 minutes after first reporting a fire, the pilot made an approach to land on runway 16 at Cootamundra. He reported that when he selected the landing gear down on late final there was no indication that the gear had extended. The pilot reported that he did not have sufficient time to extend the gear manually using the emergency procedure because he was anxious to get the aircraft on the ground as quickly as possible. Unaware that the right main landing gear had extended the pilot advised the passengers to prepare for a ‘belly’ landing. He lowered full flap, selected the propeller levers to the feathered position and the condition levers to fuel cut-off. The aircraft landed with only the right main landing gear extended. The right main wheel touched down about 260 m beyond the runway threshold, about one metre from the right edge of the runway. During the landing roll the aircraft settled on the nose and the left engine nacelle and skidded for approximately 450 m before veering left off the bitumen. The soft grass surface swung the aircraft sharply left, and it came to a stop on the grass flight strip east of the runway, almost on a reciprocal heading. The pilot and passengers were uninjured, and vacated the aircraft through the cabin door and left overwing emergency exit. Personnel from a maintenance organisation at the aerodrome extinguished the fire in the right engine nacelle using portable fire extinguishers.
Probable cause:
Significant factors:
1. Vibration from the worn armature shaft of the right starter generator resulted in a fractured fuel return line.
2. The armature shaft of the right engine starter generator failed in-flight.
3. Sparks or frictional heat generated by the failed starter generator ignited the combustible fuel/air mixture in the right engine accessory compartment.
4. Items on the engine fire emergency checklist were not completed, and the fire was not suppressed.
5. The operator’s CASA approved emergency checklist did not contain smoke evacuation procedures.
6. The pilot did not attempt to extend the landing gear using the emergency gear extension when he did not to get a positive indication that the gear was down and locked.
7. The aircraft landed on the right main landing gear and slid to a stop on the right main gear, left engine nacelle and nose.
Final Report:

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: