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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 Britten-Norman BN-2A-21 Islander in Coolangatta

Date & Time: Apr 7, 1996 at 2138 LT
Type of aircraft:
Registration:
VH-HIA
Survivors:
Yes
Schedule:
Tangalooma – Coolangatta
MSN:
415
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
881
Captain / Total hours on type:
177.00
Circumstances:
The aircraft was the third in a stream of five company aircraft departing the Tangalooma Resort airstrip at two-minute intervals on a clear moonlit evening. Following a routine departure at 2105 EST, the aircraft was climbed to 3,000 ft for the flight back to Coolangatta. Early in the cruise phase of the flight, the pilot found that the fourth aircraft was catching up to his and he elected to descend to 2,000 ft to ensure continued separation. At 2127 EST, the pilot reported to Coolangatta Approach Control that the aircraft had severe problems, but did not inform the controller of the nature of his emergency. However, the controller activated the airport emergency procedures when he observed on his radar display that the aircraft was losing altitude. The pilot had his second VHF radio transceiver tuned to his company frequency, and was answering transmissions received from other company pilots on this frequency while transmitting on the Coolangatta Approach frequency. The pilot later said that after the aircraft passed the seaway at Southport, the right engine surged, which resulted in the aircraft yawing. After he switch the electric fuel pump to "on", the symptoms disappeared. About a minute later he switched the pump off, then on again. He said that when the engine began surging again, he shut the engine down, feathering the propeller. Left engine power was increased and the aircraft maintained 1,500 ft in level flight. He switched the left engine's fuel supply to the right main tank, believing that this action would ensure supply from both main fuel tanks. The pilot said that after the aircraft passed Burleigh Heads, many things appeared to go wrong at once. The left engine began to splutter and did not respond to the throttle. He recalled attempting to restart the right engine. This proved to be unsuccessful. As the descent continued he planned to land on a beach. The pilot selected a stretch of beach for a forced landing. During late final approach, aided by bright moonlight, he noticed that any overrun would take the aircraft into a crowded car park. He changed his aim point to the stretch of beach south of the Currumbin Lifesavers Clubhouse. Following the flare for landing, the right wing struck a low rocky outcrop and the aircraft crashed into the surf. The entire wing assembly separated from the fuselage, which came to rest on its left side. Some of the nine passengers, and the pilot, escaped from the semi-submerged fuselage while bystanders rescued others.
Probable cause:
The following findings were reported:
1. The pilot shut down an engine following surging but did not feather the propeller.
2. The aircraft was not flown at (or near) its best single-engine performance speed after the right engine was shut down.
Final Report:

Crash of a Partenavia P.68B in Tangalooma

Date & Time: Nov 22, 1995 at 2110 LT
Type of aircraft:
Registration:
VH-TLQ
Flight Phase:
Survivors:
Yes
Schedule:
Tangalooma – Coolangatta
MSN:
33
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
905
Captain / Total hours on type:
57.00
Circumstances:
The aircraft was the second to take off in a stream of six on a night flight from the Tangalooma Resort strip to Coolangatta aerodrome. Shortly after takeoff it struck the ground, nosed over and was consumed by a fuel-fed fire. The take-off run appeared normal but the initial climb was shallow according to the witnesses, some of whom were pilots waiting their turn to take off. At about 150 ft above ground level the aircraft entered a descent which continued until ground impact, 164 m beyond the departure end of the strip. The nose gear collapsed at impact but the aircraft remained upright and skidded along the ground on its main gear and front fuselage. It traversed a low sand dune, fell 10 ft to the beach and overturned. The aircraft came to rest 112 m beyond the first ground contact. All four passengers were able to evacuate the aircraft which had started to burn. The pilot was rescued by her passengers.
Probable cause:
The following factors were reported:
1. The takeoff direction was dark and had no visible horizon.
2. The elevator trim was not set for takeoff.
3. The elevator load on takeoff was high.
4. The pilot did not monitor the aircraft attitude after lift-off.
5. The flap was retracted in one movement, increasing the elevator load.
6. The pilot may have been affected by somatogravic illusion to the extent that she thought the climb attitude was adequate.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Coffs Harbour: 3 killed

Date & Time: Apr 7, 1988 at 2113 LT
Operator:
Registration:
VH-AOX
Survivors:
Yes
Schedule:
Brisbane – Coolangatta – Coffs Harbour – Port Macquarie
MSN:
31-7552013
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The aircraft was operating a scheduled service from Brisbane to Port Macquarie with planned intermediate stops at Coolangatta and Coffs Harbour. Weather conditions over the route were influenced by a widespread unstable airmass. The terminal forecast for Coffs Harbour indicated a surface wind of 360/15, visibility in excess of 10 km, 5 octas stratus at 1000 ft, 5 octas cumulus at 2000 ft. Thunderstorms, associated with visibility reduced to 2000 metres were also forecast for periods of up to 30 minutes. The actual weather conditions at Coffs Harbour were generally consistent with the terminal forecast. Runway 03 was in use throughout the evening. Coffs Harbour airport was equipped with NDB, VOR and domestic DME radio navigation aids. A VOR/DME procedure was published for runway 03 approaches. For aircraft not equipped with DME, a VOR or NDB approach was available using common tracking and minimum altitude criteria. Runway 03 was also equipped with a 6 stage T-VASIS and 3 stage runway lighting. All facilities were reported as functioning normally, with the exception of the VOR which was experiencing intermittent power failures due to the effects of heavy rain. The VOR was able to be reset manually from the Coffs Harbour control tower. Although the tower was scheduled to be unmanned before the arrival of VH-HOX, the duty air traffic controller elected to man the tower until the aircraft had landed. The controller also called out a technician to attend to the VOR. The aircraft was equipped with dual ILS/VOR and ADF receivers, plus International DME. Domestic DME equipment was not fitted to the aircraft, although required by ANO 20.8. After descending in the VOR/NDB holding pattern, the aircraft was cleared for an instrument approach. The pilot had been told of the intermittent operation of the VOR and had said he would revert to the NDB. At that time the weather conditions were fluctuating about the circling minima of 950 feet (QNH) and five km visibility. The controller advised the aircraft of a heavy shower to the south of the field. The aircraft subsequently completed the approach and the pilot reported "visual". The controller said he saw the lights of the aircraft in a position consistent with a right downwind leg for a landing on runway 03. The aircraft was then cleared to land. Shortly after, the controller saw the lights of the aircraft disappear briefly, consistent with the aircraft passing through a localised area of rain/cloud. The lights then reappeared briefly, as though the aircraft was turning onto finals, before disappearing. This was immediately followed by short series of "clicks" on the tower frequency. The aircraft was called immediately but failed to respond to any calls. The accident site was located about 1070 metres short of the landing threshold, and about 750 metres to the right of the extended runway centreline. The aircraft was found to have initially struck a nine metre high tree in a nose low attitude, steeply banked to the right, on a track of 050 degrees. After striking the tree with the outboard section of the right wing, the aircraft struck other trees before hitting the ground and overturning. A fire broke out shortly after the aircraft came to rest. As a result of his remaining on duty, the controller was able to provide immediate notification of the accident to the emergency services. This action facilitated the rescue of survivors.
Probable cause:
A subsequent examination of the aircraft structure, systems and components, found no evidence of any pre-existing defect or malfunction which could have contributed to the accident. The pilot was properly licenced and qualified to conduct the flight. Evidence was provided to show that the pilot had probably flown a total of 930 hours in the previous 365 days, thereby exceeding the ANO 48 limitation of 900 hours. Other breaches of Flight and Duty Limitations were found to have occurred during the previous 12 months, however, during the three months prior to the accident no significant breaches of ANO 48 were found which could have contributed to the accident. Specialist medical advice considered the 30 hour exceedence of the 900 hour limitation was not significant in this accident. Other specialist advice was obtained concerning the possibility of the aircraft being affected by low level windshear or a microburst during the final stage of the night circling approach. It was considered this was not a factor in the accident. Considerable evidence was presented during a subsequent Coroners' Inquest concerning allegations of irregular operating practices by the operator over a period of several years prior to the accident. Much of this evidence was only provided after the granting to witnesses of immunity from prosecution. Despite this, no new evidence was presented which related to the accident flight. The investigation concluded that, on the evidence available, the aircraft was turning onto a short right base leg when it entered a localised area of rain and low cloud. The pilot was required to look out of the right cockpit window to enable him to maintain visual reference with the approach end of the runway. It is considered probable that the pilot briefly diverted his attention from the flight instruments while attempting to maintain that visual reference as the aircraft passed through an area of reduced visibility. During that period the aircraft continued to roll to the right, resulting in an inadvertent loss of height. The pilot was unable to effect a recovery before the aircraft struck trees.
The following factors were considered relevant to the development of the accident:
1. Low cloudbase, with localised rain squalls and reduced visibility.
2. Low level, right hand, night circling approach.
3. Pilot lost visual reference at a critical stage of the approach.
4. Pilot did not initiate missed approach.
5. Pilot probably diverted attention from the flight instruments.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601B) in Lismore: 1 killed

Date & Time: Mar 11, 1986 at 1659 LT
Operator:
Registration:
VH-CUO
Flight Type:
Survivors:
No
Schedule:
Coolangatta – Lismore
MSN:
61-0806-8062151
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
When the aircraft arrived in the destination area, another aircraft was also in the circuit. The pilots were in communication with each other, and arranged that VH-CUO would land after the other aircraft. However, the pilot of VH-CUO apparently misjudged the relative speeds of the two aircraft. He initiated a go-around from a position on final approach to runway 15, when there was evidently insufficient separation with the preceding aircraft to allow a normal landing. The aircraft remained at a low height above the ground, and the pilot broadcast a message that he intended to land in the opposite direction, on runway 33. The wind at the time was from the south-east at about 10 knots. Witnesses observed the aircraft as it tracked along the western side of the runway. The turn onto base leg was made at an angle of bank of about 60 degrees, and about three-quarters of the way around the turn, the nose of the aircraft dropped rapidly. The aircraft then dived steeply to the ground, and was destroyed by the impact and subsequent fire.
Probable cause:
The subsequent investigation did not reveal any defect or malfunction which might have affected the operation of the aircraft. The pilot was conducting an operation known as a "bank run", and there is pressure on pilots performing such runs to adhere to the prescribed schedules. The pilot's decision to perform a low level circuit and land downwind was considered to be related to his desire to arrive at the terminal as close as possible to the scheduled time. While conducting the circuit, the aircraft stalled during a turn at a height which was too low to allow the pilot to recover control before impact with the ground.
Final Report:

Crash of a Lockheed 18-56 LodeStar in Coolangatta: 21 killed

Date & Time: Mar 10, 1949 at 0950 LT
Type of aircraft:
Operator:
Registration:
VH-BAG
Flight Phase:
Survivors:
No
Schedule:
Coolangatta – Brisbane
MSN:
2194
YOM:
1942
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
21
Captain / Total flying hours:
2300
Copilot / Total flying hours:
1700
Circumstances:
Shortly after takeoff from Coolangatta Airport, while climbing to a height of some 250 feet, the aircraft banked right and then to the left. It went out of control and crashed in flames in a swamp. The aircraft was partially destroyed by a post impact fire and all 21 occupants were killed.
Probable cause:
The accident was caused by the aircraft being loaded so its centre of gravity was behind the rear limit. The report also stated that incorrect setting of the elevator trim tab may have been a contributory cause. The rear limit for the centre of gravity was 39% of Mean Aerodynamic Chord. The load sheet prepared for the fatal flight indicated the centre of gravity of VH-BAG was at 39.2% of Mean Aerodynamic Chord. The load sheet was based on a load chart prepared by the Department of Civil Aviation and based on information supplied by the RAAF. During the investigation, inquiries were made with the US Civil Aeronautics Administration and this revealed an error in the load chart. The main undercarriage of the Lockheed Lodestar retracted to the rear so that retraction caused the centre of gravity to move rearwards but this was not taken into account in the design of the load chart. Other errors also came to light. The passenger seats were 1 inch (25 mm) further apart than shown on the load chart, causing the centre of gravity to be further to the rear than calculated, especially when the aircraft was fully loaded. Up to 18 kilograms (40 lb) of food and beverages for the passengers were stored at the rear of the passenger cabin but were not taken into account on the load chart. Investigation of the accident concluded that after the aircraft's undercarriage retracted, the centre of gravity would have been at about 43.4% of Mean Aerodynamic Chord. With the centre of gravity 4% of MAC behind the rear limit the aircraft would have been tail-heavy and longitudinally unstable. The aircraft had been in daily civil operations in Australia since November 1946 so the investigators assumed there must have been numerous flights with the centre of gravity significantly more than 39% of Mean Aerodynamic Chord. It was necessary for the investigators to find something unique about the fatal flight of VH-BAG that would explain its sudden climb immediately after take-off and the pilot's inability to regain control and prevent the aircraft crashing. The aircraft's tail was one of the few parts of the aircraft not destroyed by fire. The position of the elevator trim tab spool appeared to be in the normal position for landing rather than a typical position for take-off. The investigators concluded that on the final takeoff it was likely that the elevator trim tab was still set for landing. This, coupled with the aircraft being tail-heavy and longitudinally unstable after undercarriage retraction, caused the aircraft to pitch nose-up so strongly that the pilot was unable to retain control or prevent the aircraft stalling. Minister for Civil Aviation Arthur Drakeford made a public announcement that the accident had occurred because the aircraft was tail-heavy and unstable as the result of incorrect loading. The Minister said the operator had not taken adequate steps to ensure safe loading of its aircraft and he hinted that stricter regulation of the loading of aircraft was being considered.