Crash of a Cirrus Vision SF50 in Lansing

Date & Time: Aug 24, 2021 at 1858 LT
Type of aircraft:
Operator:
Registration:
N1GG
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lansing – Melbourne
MSN:
0202
YOM:
2020
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2000
Captain / Total hours on type:
600.00
Aircraft flight hours:
293
Circumstances:
The airport tower controller initially assigned the pilot to take off from runway 28L, which presented a 7-knot headwind. Shortly afterward, the controller informed the pilot of “a storm rolling in . . . from west to east,” and offered runway 10R. The pilot accepted the opposite direction runway for departure and added, “we’re ready to go when we get to the end . . . before the storm comes.” About 4 seconds after the airplane began accelerating during takeoff, the controller advised the pilot of a wind shear alert of plus 20 knots (kts) at a 1-mile final for runway 28L, and the pilot acknowledged the alert. In a postaccident statement, the pilot stated that departing with a 7-kt tailwind was within the operating and performance limitations of the airplane. The pilot reported that after a takeoff ground roll of about 4,000 ft “the left rudder didn’t seem to be functioning properly” and he decided to reject the takeoff. However, when he applied full braking, the airplane tended to turn to the right. He used minimal braking consistent with maintaining directional control of the airplane. The airplane ultimately overran the runway, impacted the airport perimeter fence, and encountered a ditch before it came to a rest. A postimpact fire ensued and consumed a majority of the fuselage. All four occupants evacuated safely.
Probable cause:
The pilot’s decision to depart with a tailwind as a thunderstorm approached, which resulted in a loss of airplane performance due to an encounter with a significant tailwind gust and a subsequent runway excursion.
Final Report:

Crash of a Rockwell Shrike Commander 500S in Clonbinane: 2 killed

Date & Time: Jul 31, 2007 at 2000 LT
Operator:
Registration:
VH-YJB
Flight Phase:
Survivors:
No
Site:
Schedule:
Melbourne – Shepparton
MSN:
500-3299
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2342
Captain / Total hours on type:
970.00
Aircraft flight hours:
4558
Circumstances:
At 1946 Eastern Standard Time on 31 July 2007, a Rockwell International Aero Commander 500S, registered VH-YJB (YJB), departed Essendon Airport, Vic. on a business flight to Shepparton that was conducted at night under the instrument flight rules (IFR). On board were the pilot and one passenger. At 1958, while in the cruise at 7,000 ft above mean sea level (AMSL) in Class C controlled airspace, radar and radio contact with the aircraft was lost simultaneously by air traffic control when it was about 25 NM (46 km) north-north-east of Essendon. The air traffic controller declared a distress phase after a number of unsuccessful attempts to contact the pilot. At 2003, the Operations Director at Melbourne Centre declared the aircraft as probably lost and advised AusSAR. A search was commenced using a helicopter and an aeroplane in addition to ground search parties. No emergency locator transmitter signal was reported. At 2147, aircraft wreckage was located by a searching aircraft in timbered ranges near Clonbinane, approximately 50 km north of Melbourne. At about 2200, a ground search party confirmed that the wreckage was that of YJB and that there were no survivors. The flight was arranged to take the company owner, who was also a licensed aircraft maintenance engineer (LAME), to Shepparton to replace an unserviceable starter motor in another of the operator‟s aircraft. The pilot, who had landed at Essendon at 1915 from a previous flight in another of the operator‟s aircraft, was tasked to fly the owner to Shepparton. The pilot transferred to YJB, which had previously been prepared for flight by another company pilot. At 1938, while taxiing for takeoff, the pilot advised the aerodrome controller of the intention to conduct the IFR flight, adding, „…and request a big favour for a submission of a flight plan, with an urgent departure Essendon [to] Shepparton [and] return‟. The aerodrome controller did not have the facilities for processing flight notifications and sought the assistance of a controller in the Melbourne air traffic control centre. There were no eyewitnesses to the accident. Residents living in the vicinity of the accident site were inside their homes and reported difficulty hearing anything above the noise made by the wind and the foliage being blown about. One of the residents reported hearing a brief, loud engine noise. Another resident thought the noise was that of a noisy vehicle on the road. The noise was described as being constant, „…not spluttering or misfiring‟ and lasted for only a few seconds. Some of those residents near the accident site reported hearing and feeling an impact only moments after the engine noise ceased. The aircraft was seriously damaged by excessive in-flight aerodynamic forces and impact with the terrain. The vegetation in the immediate vicinity of the main aircraft wreckage was slightly damaged as the aircraft descended, nearly vertically, through the trees. The pilot and passenger were fatally injured.
Probable cause:
Structural failure and damage:
From the detailed examination and study of the aircraft wreckage undertaken by ATSB investigation staff, it was evident that all principal structural failures had occurred under gross overstress conditions i.e. stresses significantly in excess of the physical strength of the respective structures. The examination found no evidence of pre-existing cracking, damage or material degradation that could have appreciably reduced the strength of the failed sections, nor was there any indication that the original manufacture, maintenance or repair processes carried out on the aircraft were in any way contributory to the failures sustained.

Breakup sequence:
From the localised deformation associated with the spar failures, it was evident that the aircraft had sustained a large negative (downward) loading on the wing structure. That downward load resulted in the localised bending failure of the wing around the station 145 position (145” outboard of the aircraft centreline). The symmetry of both wing failures and the absence of axial twisting within the fuselage section suggested that the load encountered was sudden and well in excess of the ultimate strength of the wing structure. Based upon the witness marks on both wing under-surfaces and the crushing and paint transfer along the leading edges of the horizontal stabilisers, it was concluded that after separating from the inboard structure, both wings had moved aft in an axial twisting and rotating fashion; simultaneously impacting the leading edges of both horizontal tailplanes. Forces imparted into the empennage structure from that impact subsequently produced the rearward separation of the complete empennage from the fuselage. The loss of the left engine nacelle fairing was likely brought about through an impact with a section of wing leading edge as it rotated under and to the rear. The damage sustained by all of the aircraft‟s control surfaces was consistent with failure and separation from their respective primary structure under overstress conditions associated with the breakup of the aircraft. There was no evidence of cyclic or oscillatory movement of the surfaces before separation that might have suggested the contribution of an aerodynamic flutter effects.

Findings
The following statements are a summary of the verified findings made during the progress of the aircraft wreckage structural examination and analysis:
- All principal failures within the aircraft wings, tailplanes and empennage had occurred as a result of exposure to gross overstress conditions.
- The damage sustained by the aircraft wreckage was consistent with the aircraft having sustained multiple in-flight structural failures.
- The damage sustained by the aircraft wreckage was consistent with the structural failure sequence being initiated by the symmetric, downward bending failure of both wing sections, outboard of the engine nacelles.
- Breakup and separation of the empennage was consistent with having been initiated by impact of the separated outboard wings with the leading edges of the horizontal stabilisers.
- There was no evidence of material or manufacturing abnormalities within the aircraft structure that could be implicated in the failures and breakup sustained.
- There was no evidence of service-related degradation mechanisms (such as corrosion, fatigue cracking or environmental cracking) having affected the aircraft structure in the areas of failure.
Final Report:

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

Date & Time: Jul 11, 2007 at 1215 LT
Operator:
Registration:
N105GC
Flight Type:
Survivors:
Yes
Schedule:
Melbourne - Orlando
MSN:
31-7652130
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13000
Captain / Total hours on type:
200.00
Circumstances:
The airplane had undergone routine maintenance, and was returned to service on the day prior to the incident flight. The mechanics who performed the maintenance did not secure the right engine cowling using the procedure outlined in the airplane's maintenance manual. The mechanic who had been working on the outboard side of the right engine could not remember if he had fastened the three primary outboard cowl fasteners before returning the airplane to service. During the first flight following the maintenance, the right engine's top cowling departed the airplane. The pilot secured the right engine, but the airplane was unable to maintain altitude, so he then identified a forced landing site. The airplane did not have a sufficient glidepath to clear a tree line and buildings, so he landed the airplane in a clear area about 1,500 yards short of the intended landing area. The airplane came to rest in a field of scrub brush, and about 5 minutes after the pilot deplaned, the grass under the left engine ignited. The subsequent brush fire consumed the airplane. Examination of the right engine cowling revealed that the outboard latching fasteners were set to the "open" position. When asked about the security of the cowling during the preflight inspection, the pilot stated that he "just missed it."
Probable cause:
The mechanic's failure to secure the right engine cowling fasteners. Contributing to the incident was the pilot's inadequate preflight inspection.
Final Report:

Crash of a Cessna 340A in Melbourne: 3 killed

Date & Time: Mar 23, 2006 at 1057 LT
Type of aircraft:
Operator:
Registration:
N37JB
Survivors:
No
Schedule:
Jacksonville – Melbourne
MSN:
340A-0124
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
801
Aircraft flight hours:
3068
Circumstances:
A commercial pilot with two passengers on a business flight was arriving at the destination airport in a light twin-engine airplane. The air traffic tower controller advised the pilot to follow a slower airplane that was on base leg. The controller subsequently asked the accident pilot if he could reduce his speed,"a little bit." The accident pilot responded that he was slowing down. Less than a minute later, the controller told the accident pilot that he was cleared to land. The accident pilot's last radio transmission was his acknowledgement of the landing clearance. The controller stated that he did not see the accident airplane other than on the radar scope, but did see a plume of smoke on the final approach course for the active runway. Ground witnesses described the airplane as flying slowly with its wings wobbling, turn right, and dive into the ground. The majority of the airplane was consumed by a post crash fire. Inspection of the flight controls and engines disclosed no evidence of any preimpact mechanical problems. Low speed flight reduces the margin between a safe operating speed and an aerodynamic stall. Wing "wobble" at low speeds is often an indicator of an incipient aerodynamic stall. Toxicological samples from the pilot’s blood detected diphenhydramine (a sedating antihistamine commonly known by the trade name Benadryl) at a level consistent with recent use of at least the maximum over-the-counter dose. Diphenhydramine is used over-the-counter for allergies and as a sleep aid, and has been shown to impair the performance of complex cognitive and motor tasks at typical doses. The FAA does not specifically prohibit the use of diphenhydramine by pilots, though Federal Air Regulation 91.17, states, in part: "No crewmember may act, or attempt to act as a crewmember of a civil aircraft...while using any drug that affects the person's faculties in any way contrary to safety..."
Probable cause:
The pilot's failure to maintain adequate airspeed to avoid a stall during the final approach to land. Contributing to the accident was the pilot's impairment due to the use of a sedating antihistamine.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in King Island-Currie: 1 killed

Date & Time: Feb 8, 1996 at 0507 LT
Operator:
Registration:
VH-KIJ
Flight Type:
Survivors:
No
Schedule:
Melbourne - King Island
MSN:
31-7405222
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5519
Captain / Total hours on type:
106.00
Circumstances:
A witness heard the aircraft pass King Island aerodrome at 0455 EST at the same time as he noticed the pilot-activated 10/28 runway lights illuminate. The pilot reported to Melbourne Control that he would be completing a runway 10, non-directional beacon (NDB) approach. A short time later he broadcast that the aircraft was at the minimum descent altitude, which is 640 feet above mean sea level (AMSL) for a runway 10 NDB approach. He also broadcast that there was a complete cloud cover. The aircraft did not enter a missed approach procedure but was heard to fly towards the south-east from overhead the NDB, which is located 1.3 km south-south-west of the centre of runway 10/28. A second witness, located near the NDB site, reported observing the aircraft's lights to the south-east. At 0507 a farmer heard the aircraft pass low over his house shortly before it crashed into trees, 3.5 km south-east of the aerodrome. The first responders arrived at the accident site at about 0530. The pilot had not survived.
Probable cause:
The pilot continued a visual approach in conditions which prevented him from maintaining adequate visual clearance from the ground or obstacles and which made visual judgement of the approach difficult. Also, the pilot probably did not recognise that the conditions were not suitable for a visual approach.
Final Report:

Crash of a GAF Nomad N.22B near Tenterfield: 4 killed

Date & Time: Sep 9, 1991
Type of aircraft:
Operator:
Registration:
A18-303
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Oakey - Melbourne
MSN:
003
YOM:
1975
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The crew was completing a training mission consisting of touch-and-go at Ag Strip located 20 km east of Tenterfield. After takeoff, while in initial climb, the twin engine aircraft struck a tree, stalled and crashed, bursting into flames. All four crew members were killed.
Crew:
Maj Lynn Hummerston,
Cpl Peter McCarthy +2 PNGDF pilots.
Probable cause:
As the aircraft was totally destroyed and due to lack of evidences, the exact cause of the accident could not be determined.

Crash of a Beechcraft 65-B80 Queen Air in Tolmie: 1 killed

Date & Time: Jul 6, 1989 at 0341 LT
Type of aircraft:
Operator:
Registration:
VH-XAE
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sydney - Melbourne
MSN:
LD-305
YOM:
1966
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
At 0341 hours EST on 6 July 1989, Beechcraft 80 Queen Air aircraft registered VH-XAE collided with high voltage power lines and descended rapidly, contacting the ground three kilometres north-east of Tolmie. The pilot, who was the only occupant, received fatal injuries. There was no fire. The aircraft was on a flight from Sydney to Melbourne cruising at 8000 feet. Persons in the accident area heard an aircraft flying very low over their houses, then observed a flash of light and heard the sound of ground impact. A ground search was commenced but due to falling snow and very poor visibility the wreckage was not found until about 0745 hours in daylight. The elevation of the ground at the accident site was approximately 2,700 feet above sea level.
Probable cause:
The exact cause of the accident could not be determined.
Final Report:

Crash of a Rockwell Aero Commander 700 in Pompano Beach: 2 killed

Date & Time: Oct 12, 1987 at 1437 LT
Registration:
N26574
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Pompano Beach – Melbourne
MSN:
700-06
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5380
Aircraft flight hours:
1565
Circumstances:
Witnesses stated that just after takeoff, the left engine started to leave a trail of white smoke, the aircraft then turned left back towards the airport and crashed into the street. Post crash examination revealed one of the left engine crankshaft counterweights failed causing the #6 cylinder connecting rod to break and puncture a hole in the upper engine case. Both propellers were found in feather. Both occupants were killed.
Probable cause:
Occurrence #1: loss of engine power (total) - mech failure/malf
Phase of operation: takeoff - initial climb
Findings
1. 1 engine
2. (c) eng assembly, crankshaft counterweights/vib damper - failure, total
3. Propeller feathering - performed - pilot in command
----------
Occurrence #2: loss of engine power (total) - nonmechanical
Phase of operation: takeoff - initial climb
Findings
4. All engines
5. (c) wrong propeller feathered - inadvertent - pilot in command
6. (f) in-flight planning/decision - poor - pilot in command
----------
Occurrence #3: loss of control - in flight
Phase of operation: takeoff - initial climb
Findings
7. (c) airspeed - not maintained - pilot in command
----------
Occurrence #4: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Douglas DC-3-209A in West Deering

Date & Time: Jun 24, 1981 at 0850 LT
Type of aircraft:
Registration:
N18949
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
West Deering – Melbourne
MSN:
2013
YOM:
1937
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
85591
Circumstances:
Shortly after takeoff from West Deering-Hawthorne-Feather Airpark, the twin engine airplane encountered difficulties to gain height and rolled left and right. It struck trees, stalled and crashed in a wooded area, bursting into flames. Both crew members were seriously injured.
Probable cause:
Stall during initial climb after the crew failed to obtain flying speed. Witnesses stated that the aircraft lifted off approximately 1,700 feet from start in a three point attitude.
Final Report:

Crash of a Rockwell Shrike Commander 500S off Hobart

Date & Time: Apr 27, 1981 at 1814 LT
Operator:
Registration:
VH-EXQ
Survivors:
Yes
Schedule:
Melbourne – Hobart
MSN:
500-1831-28
YOM:
1968
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1925
Captain / Total hours on type:
77.00
Circumstances:
Due to industrial action, normal domestic airline services had been suspended. The pilot hired the aircraft to convey persons stranded by the strike between Hobart and Melbourne. He submitted a flight plan for the proposed return flight to Melbourne that nominated operations under the Instrument Flight Rules, although he did not hold an appropriate Instrument Rating. The flight to Melbourne was completed without known incident. After refuelling the aircraft and engaging five passengers, the return flight was commenced. A fare was paid by each passenger although the pilot did not hold either a Charter Licence or an appropriate pilot licence. There was considerable cloud in the vicinity of Hobart Airport which, at 1800 hours, was recorded as one okta stratus, base 800 feet; five oktas stratocumulus, base 3000 feet; five oktas altocumulus, base 11,000 feet. The surface wind was a light westerly, and the runway in use was Runway 30. There were rain showers in the area and the runway was wet. The end of daylight was at approximately 1748 hours. When the pilot of VH-EXQ contacted Hobart Tower at approximately 1800 hours, he reported on descent to 7000 feet and 50km from the airport. As the aircraft proceeded, the Aerodrome Controller cleared it for further descent in stages, to provide vertical separation from a preceding aircraft. The only Instrument Landing System (ILS) approach at Hobart Airport was aligned with Runway 12 and the tailwind for a landing in that direction was only two or three knots. In order to expedite their arrivals, the Aerodrome Controller offered the pilot s of both approaching aircraft the option of a straight-in ILS approach to Runway 12 instead of a circling approach to the into-wind Runway 30. Both pilots accepted. At 1803 hours, the preceding aircraft was cleared for an ILS approach. The pilot of VH-EXQ was then advised to expect the same clearance but, to ensure continued separation from the other aircraft, was instructed to make one circuit of the holding pattern at Tea Tree Locator, a navigational radio aid west of the airport. The pilot misunderstood this instruction and, on reaching Tea Tree at about 1805 hours, he continued towards the airport. At 1807 hours, the Aerodrome Controller cleared VH-EXQ for an ILS approach. The pilot acknowledged this instruction in the normal manner and did not advise that he had already commenced the approach. In descending towards the airport the pilot had maintained a high airspeed of nearly 200 knots. From overhead Tea Tree he could see the lights of the preceding aircraft and endeavoured to reduce his speed so as to maintain separation. As a result, the aircraft was still very high as it approached the runway. This was noted by the Aerodrome Controller and, at 1810 hours, he asked the pilot whether he would be able to land on Runway 12 or would prefer to make an approach for Runway 30. The pilot chose the latter and was cleared to a right base leg for Runway 30. The approach to Runway 12 was abandoned and the aircraft turned left onto a close right downwind leg for Runway 30. The landing gear, which had been extended, and the flaps, which had been set at 1/4 down, were not moved from these positions. The pilot reported that at some stage of the approach to Runway 30 he moved the throttles forward to increase power and maintain height. In response the aircraft yawed slightly to the right. Both propeller levers were then pushed fully forward, both throttles were fully opened and the mixture controls were checked in the full-rich position. The aircraft again swung to the right. Identifying this as evidence that the right engine had failed, and after checking from the tachometer that the right propeller was windmilling at about 1500 RPM, the pilot feathered the right propeller and selected the landing gear and flaps up. He believed that he carried out the feathering action at a height of about 300 feet and an airspeed of about 100 knots. At this time the aircraft was heading southwest, towards Single Hill (elevation 680 feet) on the shore of Frederick Henry Bay. The pilot reported that the aircraft would not maintain height or airspeed and he therefore turned left to avoid the hill. The wings were then held level until the aircraft touched down in the bay. After the aircraft turned right at a close base leg position, but then straightened on a southwesterly heading instead of continuing the turn onto final approach, the Aerodrome Controller asked the pilot to confirm that he was tracking for Runway 30. This transmission was not answered and the Aerodrome Controller again called the aircraft. The pilot then reported that he was having trouble with the right engine and he was going to feather. This transmission was made as the aircraft was approaching Single Hill, just before it turned left and descended from view. There were no further transmissions from the aircraft despite a number of calls by the Aerodrome Controller. The Distress Phase of Search and Rescue (SAR) procedures was declared at 1815 hours. The appropriate emergency services were alerted including a helicopter that was on standby for SAR operations. All six occupants were rescued while the aircraft sank and was lost.
Probable cause:
The probable cause of the accident was that, following an apparent loss of power by the right engine, the pilot did not operate the aircraft in the configuration and at the airspeed necessary for safe single-engine flight. The pilot's responses may have been Influenced by operating under Instrument Flight Rules conditions, for which he was not qualified. The cause of the reported loss of power by the right engine was not determined. The following defects were discovered:
- General mechanical wear in left engine,
- Left engine fuel injector system outside manufacturer's specifications,
- Slight timing fault in one magneto on right engine.
Final Report: