Richmond

The Board of Inquiry concluded that the instructor devised a demonstration of asymmetric flight that was 'inherently dangerous and that was certain to lead to a sudden departure from controlled flight' and that he did not appreciate this. The Board noted there were deficiencies in the acquisition and documentation of 707 operational knowledge within the RAAF combined with the absence of effective mechanisms to prevent the erosion of operational knowledge at a time when large numbers of pilots were resigning from the air force. There was no official 707 QFI conversion course and associated syllabus and no adequate QFI instructors' manual. There were deficiencies in the documented procedures and limitations pertaining to asymmetric flight in the 707 and a lack of fidelity in the RAAF 707 simulator in the flight regime in which the accident occurred, which, assuming such a requirement existed, required actual practise in flight. 'The captain acted with the best of intentions but without sufficient professional knowledge or understanding of the consequences of the situation in which he placed the aircraft,' the Board said.

A failure of one engine for undetermined reasons. Additionally, the heavy gross weight resulted in inadequate single engine performance, which lead to a forced landing.

The National Transportation Safety Board determines that the probable cause of this accident was a failure of the flight crew to maintain a proper flightpath. Contributing to the accident were the ineffective management and supervision of flight crew training and flight operations, and ineffective FAA surveillance of AVAir.

Occurrence #1: loss of engine power (partial) - nonmechanical
Phase of operation: approach - faf/outer marker to threshold (ifr)
Findings
1. (c) fluid, fuel - exhaustion
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Occurrence #2: loss of engine power (total) - nonmechanical
Phase of operation: approach - faf/outer marker to threshold (ifr)
Findings
2. (c) fluid, fuel - starvation
3. (c) emergency procedure - not understood - pilot in command
4. (c) improper training - company/operator management
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Occurrence #3: in flight collision with terrain/water
Phase of operation: approach - faf/outer marker to threshold (ifr)
Findings
5. Object

Stall during initial climb due to the failure of the elevator tab control system. It was determined that the elevator swage fitting was binding on bulkhead raceway station 63.

The aircraft went out of control upon landing after the crew failed to extend the landing gear. The following contributing factors were reported:
- Failed to maintain flying speed,
- Diverted attention from operation of aircraft,
- Examination of runway revealed prop slash marks right and left of runway centerline,
- Right propeller damaged, one blade broken, left propeller damaged.

Inadequate preflight preparation on part of the pilot who failed to deice the airplane that was contaminated by frost on wings.

Wheels-up landing caused by the malfunction of the landing gear mechanism. The following contributing factors were reported:
- Improper maintenance on part of the maintenant personnel,
- Failure of the landing gear mechanism,
- Material failure, corrosion,
- Suspected mechanical discrepancy,
- Numerous aircraft maintenance discrepancies,
- Uplock cable broken,
- Emergency system pressure too low.

The accident was probably caused by the combination of the following factors:
- Engine failure or malfunction during takeoff,
- Inadequate supervision of flight,
- The crew failed to maintain flying speed,
- Improper emergency procedures,
- The instructor cut the right engine after liftoff and the pilote retarded wrong throttle and failed to raise the flaps.