Melbourne-Essendon

On 21 February 2017, the pilot of a Beechcraft B200 King Air aircraft, registered VH-ZCR (ZCR), and operated by Corporate & Leisure Aviation, was conducting a charter passenger flight from Essendon Airport, Victoria to King Island, Tasmania. There were four passengers on board. ZCR had been removed from a hangar and parked on the apron the previous afternoon in preparation for the flight. The pilot was first seen on the apron at about 0706 Eastern Daylight-saving Time. Closed-circuit television recorded the pilot walking around the aircraft and entering the cabin, consistent with conducting a pre-flight inspection of the aircraft. At about 0712, the pilot entered ZCR’s maintenance provider’s hangar. A member of staff working in the hangar reported that the pilot had a conversation with him that was unrelated to the accident flight. The pilot exited the hangar about 0715 and had a conversation with another member of staff who reported that their conversation was also unrelated to the accident flight. The pilot then returned to ZCR, and over the next 4 minutes he was observed walking around the aircraft. The pilot went into the cabin and re-appeared with an undistinguishable item. The pilot then walked around the aircraft one more time before re-entering the cabin and closing the air stair cabin door. At about 0729, the right engine was started and, shortly after, the left engine was started. Airservices Australia (Airservices) audio recordings indicated that, at 0736, the pilot requested a clearance from Essendon air traffic control (ATC) to reposition ZCR to the southern end of the passenger terminal. ATC provided the clearance and the pilot commenced taxiing to the terminal. At the terminal, ZCR was refueled and the pilot was observed on CCTV to walk around the aircraft, stopping at the left and right engines before entering the cabin. The pilot was then observed to leave the aircraft and wait for the passengers at the terminal. The passengers arrived at the terminal at 0841 and were escorted by the pilot directly to the aircraft. At 0849, the left engine was started and, shortly after, the right engine was started. At 0853, the pilot requested a taxi clearance for King Island, with five persons onboard, under the instrument flight rules. ATC instructed the pilot to taxi to holding point 'TANGO' for runway 17, and provided an airways clearance for the aircraft to King Island with a visual departure. The pilot read back the clearance. Airservices Automatic Dependent Surveillance Broadcast (ADS-B) data (refer to section titled Air traffic services information - Automatic Dependent Surveillance Broadcast data) indicated that, at 0854, ZCR was taxied from the terminal directly to the holding point. The aircraft did not enter the designated engine run-up bay positioned near holding point TANGO. At 0855, while holding at TANGO, the pilot requested a transponder code. The controller replied that he did not have one to issue yet. Two minutes later the pilot contacted ATC and stated that he was ready and waiting for a transponder code. The controller responded with the transponder code and a clearance to lineup on runway 17. At 0858, ATC cleared ZCR for take-off on runway 17 with departure instructions to turn right onto a heading of 200°. The pilot read back the instruction and commenced the takeoff roll. The aircraft’s take-off roll along runway 17 was longer than expected. Witnesses familiar with the aircraft type observed a noticeable yaw to the left after the aircraft became airborne. The aircraft entered a relatively shallow climb and the landing gear remained down. The shallow climb was followed by a substantial left sideslip, while maintaining a roll attitude of less than 10° to the left. Airservices ADS-B data indicated the aircraft reached a maximum height of approximately 160 ft above ground level while tracking in an arc to the left of the runway centreline. The aircraft’s track began diverging to the left of the runway centreline before rotation and the divergence increased as the flight progressed. Following the sustained left sideslip, the aircraft began to descend and at 0858:48 the pilot transmitted on the Essendon Tower frequency repeating the word ‘MAYDAY’ seven times in rapid succession. Approximately 10 seconds after the aircraft became airborne, and 2 seconds after the transmission was completed, the aircraft collided with the roof of a building in the Essendon Airport Bulla Road Precinct - Retail Outlet Centre (outlet centre), coming to rest in a loading area at the rear of the building. CCTV footage from a camera positioned at the rear of the building showed the final part of the accident sequence with post-impact fire evident; about 2 minutes later, first responders arrived onsite. At about 0905 and 0908 respectively, Victoria Police and the Metropolitan Fire Brigade arrived. The pilot and passengers were fatally injured and the aircraft was destroyed. There was significant structural, fire and water damage to the building. Additionally, two people on the ground received minor injuries and a number of parked vehicles were damaged.

On 8 July 2005, the pilot of a Piper PA-31-350 Navajo Chieftain, registered VH-OAO, submitted a visual flight rules (VFR) flight plan for a charter flight from Essendon Airport to Mount Hotham, Victoria. On board the aircraft were the pilot and two passengers. At the time, the weather conditions in the area of Mount Hotham were extreme. While taxiing at Essendon, the pilot requested and was granted an amended airways clearance to Wangaratta, due to the adverse weather conditions at Mount Hotham. The aircraft departed Essendon at 1629 Eastern Standard Time. At 1647 the pilot changed his destination to Mount Hotham. At 1648, the pilot contacted Flightwatch and requested that the operator telephone the Mount Hotham Airport and advise an anticipated arrival time of approximately 1719. The airport manager, who was also an accredited meteorological observer, told the Flightwatch operator that in the existing weather conditions the aircraft would be unable to land. At 1714, the pilot reported to air traffic control that the aircraft was overhead Mount Hotham and requested a change of flight category from VFR to instrument flight rules (IFR) in order to conduct a Runway 29 Area Navigation, Global Navigation Satellite System (RWY 29 RNAV GNSS) approach via the initial approach fix HOTEA. At 1725 the pilot broadcast on the Mount Hotham Mandatory Broadcast Zone frequency that the aircraft was on final approach for RWY 29 and requested that the runway lights be switched on. No further transmissions were received from the aircraft. The wreckage of the aircraft was located by helicopter at 1030 on 11 July. The aircraft had flown into trees in a level attitude, slightly banked to the right. Initial impact with the ridge was at about 200 ft below the elevation of the Mount Hotham aerodrome. The aircraft had broken into several large sections and an intense fire had consumed most of the cabin. The occupants were fatally injured.

The pilot had planned to conduct a night charter flight over Melbourne and Port Phillip Bay, starting from and returning to Essendon Airport. Dinner was to be served in flight. The pilot gave a safety briefing to the passengers before starting the engines. He completed engine runups and pre-takeoff checks, including selecting 20° of flap. At 2036 ESuT, in daylight, the pilot initiated takeoff on runway 17 using standard take-off power setting of 7.5 lb/in2 of boost and 3,000 RPM. Wind conditions were light and variable, visibility was about 10 km and the temperature was 19°C. The aircraft became airborne and, just as it achieved the take-off safety speed of 84 kts, at a height not above 50 ft, the right engine lost power. The aircraft yawed right. The pilot reported to the investigation team that he briefly noticed a reading of 3 lb of boost on the MAP gauge and assessed the problem as a possible partial right engine failure. He then selected the landing gear up but it did not retract. He cycled the landing gear selector once and the gear then retracted. By this time several seconds had elapsed and the airspeed had decayed to 76 kts. The pilot then assessed the airspeed as too low to retract the flaps and left them at 20°. The airspeed continued to decay until VMCA, 72 kts, was reached. When indicated airspeed had further decayed to 68 kts, the pilot reduced power on the left engine to avoid an uncontrollable roll to the right. He was able to maintain wings level and attempted to track the aircraft toward a street but was unable to maintain height. The aircraft collided with powerlines and then struck the roofs of several houses before coming to rest, on its left side, against the front wall of a house. About one minute had elapsed from initiation of takeoff until the accident. The pilot and all but one of the passengers remained conscious throughout the accident sequence. All occupants were evacuated, some without assistance and others with the assistance of the pilot, other passengers, emergency services personnel or bystanders.

The pilot reported that whilst enroute from Essendon to Wonthaggi he descended to the lowest safe altitude of 3600 feet above sea level, lowered the landing gear, reduced power and airspeed to counter the effect of turbulence and entered a holding pattern to the south south west of the Wonthaggi navigation aid. During the holding pattern the aircraft descended until it collided with trees that were 865 feet above sea level. The weather at the time included gale force winds, rain and low cloud. There were no thunderstorms or microbursts in the area, however, other aircraft reported a very low cloud base and severe turbulence. A few minutes prior to the accident ground witnesses, south south west of the accident site, reported an aircraft matching the description of VH-SDV, flying below a low, misty, ragged cloud base. There was no record of another aircraft in the area at the time. Information was available which indicated that the aircraft had descended below 3600 feet during the approach to Wonthaggi. The passengers reported that the pilot gave no indication of any problem or danger. Until the impact, they believed the aircraft was descending normally for a landing at Port Welshpool.

The flight was intended to return patients to their home area following medical treatment in Melbourne. After an apparently normal take-off, the aircraft ceased climbing at about 100 feet above ground level. In response to a query from the Tower, the pilot advised that the left engine had failed, that he was feathering the propeller and would return for landing. The aircraft was seen to be deviating to the left, towards a large array of power lines. These lines extend from about 40 feet to 90 feet above the ground, and as the aircraft converged with the array it was probably below the height of the upper wires. The aircraft then suddenly veered to the left and subsequently struck the ground in a steep nose-down attitude. A fire broke out on impact and destroyed much of the wreckage. The final manoeuvre performed by the aircraft was typical of that which occurs when one engine of a twin-engine aircraft is producing considerably less power than the other, and airspeed is reduced to below that required to maintain directional control. The pilot had reported that the left engine had failed, and the loss of control as described by witnesses was consistent with a reduction of power from this engine, combined with low airspeed.

The aircraft was cleared via a Standard Instrument DEPARTURE with an unrestricted climb to Flight Level (FL) 220. The aircraft climbed on track at an average rate of 1300 ft/min until FL130. The rate of climb then reduced to 350 ft/min until FL140, when the rate of climb increased to 1800 ft/min. At FL160 the aircraft entered a near vertical descent and radar contact was lost one minute later at 3100 feet. The aircraft impacted the ground in a near vertical attitude. The pilot, sole on board, was killed.

The operator had undertaken to carry out a ship's crew exchange programme that consisted of transporting 16 persons and their baggage from Portland to Essendon and the same number back to Portland. Similar programmes had been carried out previously and it was known that the passengers usually carried considerable baggage. However, only two Piper PA-31-350 aircraft, VH-POC and VH-RNH, were assigned to the task. Prior to departure Essendon, both pilots attended the Briefing Office and prepared flight plans, intended to operate under the Instrument Flight Rules and the pilots calculated it would be necessary to load 208 minutes fuel for the first return flight to Portland. This included an additional 30 minutes fuel for holding, as was required because of forecast thunderstorm activity, with associated reduced visibility in rain, in the Essendon area. Both pilots elected to have their aircraft refuelled to capacity which, they indicated on their flight plans, would give them a total of 280 minutes endurance; 72 minutes more than required. The aircraft proceeded to Portland without known incident, arriving at about 14:00 hours. After a break for refreshments, the pilots returned to their aircraft at about 1500 hours and carried out pre-flight checks. The passengers arrived at the aerodrome in a number of vehicles. Initially the pilots began to weigh the baggage and record the weights on a manifest. The passengers were in a light-hearted mood, however, and with an atmosphere of some confusion, not all of the baggage was weighed, the manifest was not completed and no individual weights were marked on the bags.The baggage was then transported by trolleys to the aircraft and shared between them without consideration of weight. The baggage in the rear baggage area of the cabin of VH-POC was not restrained to prevent movement. The pilots decided that, by inspection, the average baggage weight per passenger was 20 kg. The accepted standard weight of 77 kg per adult passenger was also assumed. Each pilot then completed a load sheet for his aircraft, on the basis of carrying eight passengers. The sheet for VH-POC indicated that the aircraft fuel load was 290 kg. The total weight calculated for VH-POC was 3,080 kg. This was less than the maximum allowable all-up-weight of 3,178 kg. However, an incorrect aircraft operating weight had been used and an arithmetical error had occurred in the calculation. Correcting for these, the aircraft weight should have been recorded as 3,256 kg. When ready to embark, the passengers were only directed towards the two aircraft. No effort was made to split the party into two even groups and in the event, nine passengers boarded VH-POC. On boarding VH-POC, the pilot did not correct the passenger imbalance. He started both engines and proceeded to taxi for a take-off on Runway 22. Pre-take-off checks were carried out as the aircraft taxied. The weather conditions at the time were fine; visibility 15 km, temperature 22° Celsius, sea level barometric pressure 1007 millibars and surface wind from 210° to 220° magnetic, gusting from 25 to 35 knots. In such wind conditions, and because of the location near a coastal headland, there was significant turbulence present. The pilot of VH-POC had operated into Portland on numerous prior occasions and had experienced this common situation previously. The take-off run was commenced and the pilot reported that full power was obtained from both engines. He stated that at 95 kts the aircraft was rotated and, when a positive rate of climb had been established, the landing gear was retracted. Then, at a height of 60 to 70 feet, just after he had reduced power to the climb setting, the left engine suddenly lost power. Ground witnesses who observed the take-off reported that the aircraft appeared slow to accelerate. Once airborne, it maintained a low climb profile and, at one stage, slewed to the right. Irregular engine noise was heard but it was not identified to a particular engine. The pilot reported that he confirmed a left engine failure by closing the left throttle. On fully re-opening the throttle, however, he noted a slight power response and hence he elected not to shut down the engine and feather the left propeller. Several of the passengers were aware of an abnormal situation but none was aware of the nature of the problem nor could confirm which engine was malfunctioning. They reported that the landing gear audio warning was sounding throughout most of the flight, which indicated a throttle was at or near the closed position. The pilot reported that the aircraft began to lose height and, as a forced landing was imminent, he turned to the right to avoid the sea. Control had been difficult in the gusty conditions but he had managed to reduce speed, lower the landing gear and guide the aircraft to a landing in a reasonably suitable area. The aircraft touched down on undulating-, sandy scrub-covered terrain. The landing gear and engines were torn out and the aircraft came to rest after travelling only some 26 metres. The fuselage broke open near the rear door during the ground slide. Some passengers were able to evacuate the cabin without assistance and they rendered help to the pilot and other passengers. A small fire, which had ignited in the vicinity of the left engine as the aircraft came to rest, then suddenly spread and engulfed the fuselage before the final passenger could be extricated. Subsequent examination of the wreckage was hampered by the extensive fire damage. No pre-existing fault was found in those components that were recovered. An inspection of the left propeller found that it had been feathered at ground impact. It was not possible to establish precisely the aircraft's weight and centre of gravity at the time of the accident as the contents of the nose and engine nacelles baggage compartments were destroyed. The available evidence, however, indicated that the aircraft weighed at least 3400 kg and its centre of gravity was probably beyond the aft limit. Piper PA31-350 performance data indicated that, for a new aircraft, the maximum attainable single-engine rate of climb at the limit weight of 3,178 kg was 220 feet per minute. At a weight of 3,400 kg this would be reduced by about 40 percent to 134 feet per minute. At the higher weight, detracting factors such as aircraft age, turbulence and less than optimum airspeed would have precluded the aircraft from achieving a positive rate of climb. The pilot was briefly interviewed in hospital on 27.1.81. At that time he also submitted a written notification of the accident. Subsequently, he has declined, through industrial counsel, to either attend for an interview under procedures of the Air Safety Investigation Branch or to supply answers to written questions. Hence it has not been possible to fully resolve a number of safety aspects of the accident, such as aircraft loading, the nature of the power loss and subsequent aircraft handling considerations.

During the morning of August 9, 1979, the aircraft was refuelled to capacity and three drums, each with a capacity of 20 litres, were also filled with fuel and placed in the baggage compartment. The aircraft, loaded with freight, subsequently departed Essendon at 1335 hours and proceeded to Cambridge where it arrived at 1536 hours. The freight was unloaded and, at 1621 hours, the aircraft departed for Launceston where it arrived at 1653 hours. It was again loaded with freight and departed Launceston at 1720 hours bound for Flinders Island. The aircraft landed at Flinders Island several minutes after the end of daylight, which was at 1745 hours, and the freight was unloaded. On the following day, the aircraft was again loaded with freight and the pilot subsequently reported departure from Flinders Island at 1329 hours, bound for Essendon. The take-off run was observed to be longer than usual for this type of aircraft and its rate of climb appeared to be less than normal. The IFR flight plan notified by the pilot before departure indicated his intention to cruise at an altitude of 4500 feet but, at 1410 hours, he reported to Melbourne Flight Service Unit "request traffic for a descent to proceed VFE we're getting 50 knot head wind here". On being advised that there was no traffic information, the pilot reported leaving 4500 feet. At 1502 hours, the pilot established communication with Essendon Tower, reported approaching Channel 0 at 1500 feet, and "request expedite clearance". He was issued with a clearance to enter controlled airspace at 1500 feet tracking from Channel 0 to Essendon via Clifton Hill. At 1506 hours he reported at Clifton Hill and, at 1507:38 hours, he advised "I'm sorry have a Mayday appear to have a fuel problem we'll have to land on a golf course". On being asked "which golf course?, the pilot replied "oh right where we are now". No further communications were received from the aircraft. The aircraft was observed by witnesses in the Northcote area initially on a north-westerly heading towards Essendon. E was seen to be descending and the sound of the engines was not normal. After flying over the northern section of the Northcote Municipal Golf Course, the aircraft commenced a descending left turn and [passed over a power transmission line which ran in a north-south direction near the western boundary of the golf course. As the turn continued towards an easterly heading, the aircraft again passed over the power line, at a very low height, and in strong tail wind conditions struck trees bordering a fairway while in a slightly left wing down, nose down, attitude. It struck the ground heavily just beyond the trees and the main wreckage travelled a further 73 metres before it came to rest on the edge of a green in the south-eastern corner of the golf course. Detailed examination of the wreckage of the aircraft revealed no evidence of any defect or malfunction which may have contributed to the accident. There was no significant fuel in the fuel systems of the two engines and there was negligible fuel in those cells of the fuel storage system which were undamaged. There was no fire. The pilot was in full time employment as an airline captain with a major operator. He was also involved financially and managerially in Norfish Pty. Ltd. and both he and the Company had financial difficulties at that time. The flight plan submitted by the pilot before departure from Essendon on August 9 contained false names in respect of both the pilot and the operator. Neither the pilot nor Norfish Pty Ltd held a Charter or Aerial Work Licence. The maximum specified take-off weight for the aircraft was 3357 kg. for VFR operations and 3243 kg. for IFR operations. It has been calculated that the gross weight of the aircraft was 3775 kg. when it departed Essendon for Cambridge on 9.8.79 and 3746 kg. when it departed Launceston for Flinders Island on the same day. The calculated gross weight was 4061 kg. when it departed Flinders Island on the day of the accident. Although fuel was available at Cambridge and Launceston, the aircraft was not refuelled after it 'departed from Essendon. The three 20 litre drums were located in the aircraft wreckage and, although all were damaged, detailed examination indicated that they ruptured under the action of hydraulic shock and that they wert filled at the time of the accident. The total operating time of the aircraft from departure Essendon until the time of the accident was consistent with a fuel endurance which could be expected in the circumstances leading to this accident.

The twin engine airplane was engaged in a local training flight at MelBourne-Essendon Airport, carrying one instructor, a pilot under supervision and a pilot's friend as passenger. Shortly after takeoff from runway 26, while climbing to a height of 200-250 feet, the pilot-under-supervision selected the wing flaps up and, at about this time, the pilot-in-command simulated an engine failure of one engine by closing a mixture control-believed to have been the starboard engine. The pilot-under-supervision identified the 'failed' engine, exercised the appropriate engine throttle to signify this identification and indicated the essential actions which would be taken in the event of an actual engine failure. The relevant controls were not operated. Following the completion of these actions full engine power was restored by the pilot-in-command. During the course of the simulated engine failure the aircraft assumed a nose down attitude. It then descended straight ahead with full engine power, passed through electric power cables outside the airport boundary at a height of 4.15 metres above terrain, and crashed into houses 286 metres beyond the western end of the runway. All three occupants were seriously injured while six people on the ground were killed, a seventh was injured as well.

The flight departed from Essendon Airport at 0050LT. At 0122 hours the flight reported to the Melbourne Flight Service Unit (FSU) that it was then at the Westgate reporting point cruising at 3,500 feet, and its estimated time of arrival at the West Bass reporting point was 0159 hours. At 0145:44 hours VH-SJQ advised the Melbourne FSU 'we have an engine failure on the port side, we have it feathered and are returning to Melbourne'. In response to a request from the FSU the flight advised it was able to maintain height 'at the moment'. At 0148:54 VH-SJQ confirmed that 'the port engine has failed and is feathered' and shortly thereafter advised an estimated time of arrival at the Primegate reporting point en route to Essendon Airport. The Uncertainty Phase of the search and rescue procedures was declared by the Melbourne Air Traffic Control Unit (ATC). At 0151:58 hours the flight advised the Melbourne FSU 'we are making a slow descent to one five zero zero' and, in answer to a query, reported 'we're unable to maintain our height with our rated power'. The Alert Phase of the search and rescue procedures was declared by Melbourne ATC, and a Bristol 170 Mark 31 aircraft en route from Launceston to Essendon Airport was diverted to intercept VH-SJQ and act as an escort. At 0157:46 hours VH-SJQ reported 'four eight DME Wonthaggi', and shortly thereafter, reported 'tracking one eight three on the Wonthaggi VOR'. At 0203:00 hours VH-SJQ transmitted a distress call and reported 'we're passed fifteen hundred feet and still going down'. The position of the aircraft at 0203:57 hours was reported as 'on the one eight six radial Wonthaggi and we are three seven DME'. The Distress phase of the search and rescue procedures was declared by Melbourne ATC and a second northbound aircraft was diverted to intercept VH-SJQ. At 0204:32 hours VH-SJQ reported 'we're down to nine hundred feet at the moment'; at 0207:42 hours, 'at six hundred feet at the moment; at 0212:55 hours, 'two two DME'; at 0213:22 hours, altitude was 200 feet; 0214:31 hours, 'we're down to one hundred feet'; and, at 0215:23 hours, 'this is a final MAYDAY call, we are approximately one eight DME and our altimeters registering zero feet'. Melbourne FSU then transmitted a ditching report of moderate seas with a moderate south-westerly swell; this was acknowledged by VH-SJQ. The escort aircraft then heard further transmissions from VH-SJQ which indicated that both altimeters were reading zero; the crew could see the tops of waves; and DME distances of 16, 15 and 14 were transmitted, the latter being the last transmission heard from the aircraft the time being about 0218 hours. Neither of the escort aircraft sighted VH-SJQ. Post analysis of the meteorological information indicates that the weather in the area of the accident was: surface wind from 280 degrees (True) at 15 knots, scattered cumulus cloud base 2,500 feet, scattered stratus cloud base 1,200 feet, patches of sea fog, visibility 40 kilometres reducing to 4,000 metres in rain showers, temperature 12° Celsius. It is probable that the temperatures at 1,500 feet, 2,500 feet, and 3,500 feet were 9.5°, 7° and 5° Celsius respectively. The conditions were not conducive to the formation of airframe or carburettor icing, and search aircraft in the area did not encounter any such icing.