Crash of a Mitsubishi MU-2B-30 Marquise in Cairns

Date & Time: Nov 15, 1983 at 0625 LT
Type of aircraft:
Registration:
VH-CJP
Flight Type:
Survivors:
Yes
Schedule:
Townsville – Cairns
MSN:
505
YOM:
1970
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was established on final by the pilot under check. A 5 knot downwind component prevailed. The flare was commenced higher than is normal and the airspeed decreased below the optimum. The pilot did not react to prompting by the the check-pilot but, at about 20 feet, retarded the throttles. The aircraft struck the runway heavily in a left wing low attitude and the left main and nose landing gear was torn off. Command responsibility for the flight was not discussed and the check-pilot was under the misapprehension that his role was only that of safety pilot. Due to flight rescheduling, the pilot under check slept for only two and a half hours prior to commencing duty. The autopilot was unserviceable and the pilot under check flew the aircraft by hand for most of the four flight legs. During the last leg the check-pilot twice simulated an engine failure. The second failure was simulated on final approach at about 7 DME. Power was reinstated shortly afterwards and the approach continued normally until close to the threshold. At this time the pilot under check had been on duty for five and a half hours and the check-pilot for over twelve hours. Overseas research has shown that subtle errors in visual perception may be induced by an event which causes stress, and that this condition may persist for several minutes after the event. Fatigue may aggravate the problem. The errors in perception are the result of changes in focal length of the lens of the eye caused by the physiological effects of the stress resulting from the event. The experimental research and information from accident data has provided evidence that the effect of the changes in focal length may cause a pilot on final approach to perceive a runway to be on a higher plane than it actually is. In this case, with the particular combination of factors prevailing at the time, it is possible that the imposition of a simulated engine failure on approach within a few minutes prior to the final landing of a long and fatiguing night's operations caused a stress reaction in the pilot under check. The level of stress induced in this fatigued pilot may have been sufficient to cause the kind of perceptual error described above. The runway would thus appear to the pilot slightly higher than it actually was. His judgement of flare height, being based on this false perception, would therefore be incorrect.
Probable cause:
Schedule changed; auto-pilot unserviceable; both pilots fatigued; command responsibility unresolved; pilot under check misjudged flare; check-pilot did not take over in time to recover control. Possible Factor Visual perception errors resulting from stress induced by the pilot's reaction to the simulated engine failure.
Final Report:

Crash of a Beechcraft 200 Super King Air in Adavale: 12 killed

Date & Time: Aug 28, 1983 at 2145 LT
Registration:
VH-KTE
Flight Phase:
Survivors:
No
Schedule:
Windorah - Toowoomba
MSN:
BB-320
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
4203
Captain / Total hours on type:
203.00
Aircraft flight hours:
7206
Circumstances:
While cruising at an altitude of 27,000 feet in good weather conditions and just passing over the city of Adavale, the twin engine aircraft went out of control and entered a dive. It descended for about 7,000 feet when excessive g loads caused both wings and the fuselage to breakup. The wreckage was found about 3,5 km south of Adavale and all 12 occupants were killed.
Probable cause:
There is insufficient evidence to determine the circumstances and factors which led to the inflight breakup of the aircraft.
Final Report:

Crash of a De Havilland DH.114 Heron 2D in Launceston

Date & Time: Aug 4, 1983
Type of aircraft:
Operator:
Registration:
VH-CLY
Survivors:
Yes
Schedule:
Hobart - Launceston
MSN:
14122
YOM:
1957
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Launceston Airport, the aircraft was misaligned and the crew decided to initiate a go-around procedure. Gear were retracted and flaps were partially raised when the airplane lost height and struck fences. It crash landed and came to rest on the runway. All seven occupants escaped with minor injuries and the aircraft was damaged beyond repair.

Crash of a Rockwell Aero Commander 685 in the Bass Strait: 2 killed

Date & Time: Jul 17, 1983 at 1505 LT
Operator:
Registration:
VH-WJC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hobart - Melbourne
MSN:
685-12005
YOM:
1972
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
On 17 July 1983 the pilot of Rockwell (Aero Commander) 685 aircraft VH-WJC submitted a flight plan to the Hobart Briefing Office for a private category flight from Hobart to Moorabbin, tracking via Launceston and Wonthaggi. The plan indicated that the flight would be conducted under the Instrument Flight Rules (IFR) at Flight Level 120 (12 000 feet altitude on standard atmospheric pressure of 1013.2 millibars), with two persons on board. The flight plan showed that the aircraft had a fuel endurance of 220 minutes, and carried an Emergency Locator Beacon (ELB) and life jackets. There was no indication that a life raft was carried. The aircraft departed Hobart at 1352 hours and, thereafter, the pilot made the appropriate radio reports to Hobart Tower, Launceston Control and Launceston Tower. The flight apparently progressed normally until 1452 hours when the pilot advised Launceston Control, "Er Whiskey Juliet Charlie we seem to have been in trouble with er fuel here the red er warning light comes on and the gauge is down . . .".At 1454 hours the pilot transmitted a Mayday call, indicating that he was descending from Flight Level 120 on track to Bass (a position reporting point), present position was 85 nautical miles (nm) from Launceston and he would be making a controlled ditching. Launceston Control immediately initiated the Distress phase of the Search and Rescue procedures and advised the Melbourne Operational Control Centre (OCC). Further communications between the aircraft and Launceston Control indicated that the aircraft was continuing descent on track towards Wonthaggi. The last position report from the pilot, at 1500 hours, was 94 nm from Wonthaggi. The last recorded transmission from the aircraft was at 1501 hours when the pilot confirmed that there were two persons on board. There were no indications at any time from the pilot that the fuel supply had been exhausted or that either engine had failed. It was estimated that the aircraft ditched at about 1505 hours, at an approximate position of 81 nm from Wonthaggi on the planned track. No trace of the aircraft nor both occupants was found.
Probable cause:
Due to lack of evidences, the exact cause of the accident could not be determined.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Moomba: 1 killed

Date & Time: Jun 15, 1983 at 1140 LT
Operator:
Registration:
VH-DVX
Flight Phase:
Survivors:
Yes
Schedule:
Adelaide – Moomba – Dullingari
MSN:
31-7405425
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft was engaged on a charter flight from Adelaide to Moomba and Dullingari. The flight from Adelaide to Moomba was without incident and after landing the pilot parked the aircraft adjacent to the refuelling cabinets. He then assisted the passengers from the aircraft and removed baggage from the nose locker. During this period a conversation took place between the pilot and the aircraft refueller. The exact content of that conversation could not positively be determined but it appears that the pilot did not specify the type of fuel to be placed in the aircraft, only which tanks were to be fuelled. As the refueller was fuelling the aircraft, the pilot accompanied his passengers to the airport terminal. When the fuelling was completed the pilot returned, with his passengers, to the aircraft. He signed the fuel release note which showed that 263 litres of Jet A-1 (Aviation turbine fuel) had been supplied, then completed a check of the aircraft's fuel tanks to ensure no water was present in the fuel. The pilot reported that the fuel sample taken was free of water and appeared to him to be the normal fuel used by the PA-31 aircraft, AVGAS (Aviation Gasoline). The pilot and the passengers then boarded the aircraft, the engines were started and the aircraft taxied for a DEPARTURE on runway 12. During the taxiing phase the pilot completed the pre-take-off checks, these including a check that the temperatures and pressure relevant to the operation of the engine were within limits. The pilot subsequently advised that the take-off was normal and after the landing gear was raised, engine power was reduced to the standard settings for the climb. However, at about 500 feet above ground level the pilot sensed a loss of performance and noted that the indicated airspeed was 115 knots, 5 knots lower than normal. He then noticed a further decay in airspeed, accompanied by the onset of engine surging and rough running. He was unable to diagnose the cause of the loss of performance and commenced a turn back towards the aerodrome. Shortly after entering the turn the right hand engine began to misfire and feathering action was initiated for the propeller. At about this time the indicated airspeed had reduced to 85 knots, the aircraft had developed a high rate of sink and the pilot realised that impact with the ground was imminent. The aircraft initially struck the ground with the right wing, then the nose section before the fuselage made heavy contact in a flat attitude, sliding about 45 metres before coming to rest. The aircraft caught fire during the impact sequence and was completely burnt out. The pilot and two of the passengers escaped from the wreckage but attempts to assist the third passenger were thwarted by the fire.
Probable cause:
The investigation established that JET-A1 fuel had been added to the fuel tanks of VH-DVX, and of the total fuel in the tank approximately 68 percent was JET-A1 fuel. The type of engine fitted to VH-DVX is not compatible with the use of JET-A1 fuel.
Final Report:

Crash of a Mitsubishi MU-2B-60 Marquise in Bargo: 1 killed

Date & Time: May 24, 1983 at 0433 LT
Type of aircraft:
Operator:
Registration:
VH-MLU
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sydney - Melbourne
MSN:
1527
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
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.
Probable cause:
Despite an extensive investigation, the reason for the loss of control leading to this accident could not be determined. There have been several other reported occurrences involving sudden loss of control in this aircraft type and the United States Federal Aviation Administration has conducted a certification review of the type. The results of that review do not appear to indicate any factors relevant to this particular accident.
Final Report:

Crash of a Cessna 402 near Nagoorin: 1 killed

Date & Time: Feb 21, 1983 at 0405 LT
Type of aircraft:
Operator:
Registration:
VH-DIL
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Brisbane – Gladstone – Rockhampton
MSN:
402-0142
YOM:
1967
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft was engaged in operating a night freight flight from Brisbane to Gladstone and Rockhampton. The pilot departed Rockhampton as a passenger in another company aircraft at about 2100 hours the night before the accident and was flown to Caloundra. He then flew VH-DIL to Brisbane and after arriving submitted a flight plan for the return flight to Rockhampton giving an estimated time of DEPARTURE Brisbane of 0230 hours. Before DEPARTURE, however, the pilot was required to await the arrival of another aircraft so that freight could be transhipped to his aircraft. DEPARTURE from Brisbane was made at 0301 hours and at 0400 hours the pilot reported the aircraft's position over Gayndah, the pilot was instructed to call on another radio frequency at 0410 hours. No further transmissions were heard from the aircraft. The wreckage was located two days later in mountainous terrain. The aircraft had impacted the ground in a near vertical attitude. Subsequent investigation did not reveal any fault with the aircraft or its systems that could have contributed to the accident. The day before the accident the pilot rose at about 0730 hours after spending the previous night and day at a friends property near Rockhampton. He spent the day at leisure at the property before returning to Rockhampton in the afternoon. After dining at his parents home he proceeded to the airport for the flight to Caloundra. Before departing Brisbane to return to Rockhampton the only sleep the pilot would have had was about an hour on the flight to Caloundra and possibly another short period at Brisbane Airport while waiting for his aircraft to be loaded.
Probable cause:
The cause of the in-flight loss of control of the aircraft could not be determined. The pilot had had inadequate rest prior to undertaking the flight.
Final Report:

Crash of a Fokker F27 Friendship 600 in Amberley

Date & Time: Jun 9, 1982
Type of aircraft:
Operator:
Registration:
VH-TQQ
Flight Type:
Survivors:
Yes
Schedule:
Amberley - Amberley
MSN:
10388
YOM:
1969
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
33311
Aircraft flight cycles:
32482
Circumstances:
The crew as completing a local training flight at Amberley Airport. On final approach, the instructor simulated a left engine failure. The airplane lost height on short final, went into a nose-down attitude and landed hard. The nose gear collapsed and the left engine partially detached. The airplane veered off runway and came to rest. While all three crew members escaped uninjured, the aircraft was damaged beyond repair.
Probable cause:
Power was reduced on the left engine at a lower than approved altitude. Directional control was lost when the trainee applied full power on the right engine.

Crash of a Piper PA-31-310 Navajo in Dysart: 2 killed

Date & Time: Mar 3, 1982 at 0453 LT
Type of aircraft:
Operator:
Registration:
VH-CLU
Flight Type:
Survivors:
No
Schedule:
Rockhampton – Dysart
MSN:
31-588
YOM:
1969
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The aircraft was being operated on a regular freight carrying run between Dysart and Rockhampton. On the evening preceding the accident, the aircraft departed Dysart at 2045 hours, arriving at Rockhampton at 2139 hours. At 0222 hours on the following morning the pilot telephoned Brisbane Flight Service Centre to obtain an update on the weather for the return flight to Dysart. The forecast indicated that at the time of arrival at Dysart, light rain with 5 oktas of cloud at 700 feet above ground level, could be expected. The pilot nominated Rockhampton as the alternate for Dysart in the event that weather conditions at the latter aerodrome precluded a safe approach and landing. The aircraft was refuelled to give a total fuel endurance of 290 minutes, and after loading departed Rockhampton at 0354 hours. At 0435 hours, the pilot reported that descent had been commenced into Dysart and because of poor reception on High Frequency radio channels further communications with VH-CLU were relayed by another aircraft in the area, VH-EEF on Very High Frequency channels. After communications with VH-CLU, the pilot of VH-EEF advised Brisbane Flight Service Unit (FSU) at 0453 hours, that the runway lighting was not yet displayed. The runway lighting at Dysart was provided by a number of hand-lit flares. The lighting of these flares was carried out by an employee of the company operating VH-CLU, and normally took about ten minutes. On this occasion the employee had overslept and arrived at the aerodrome at about the same time that the aircraft flew overhead. At 0501 hours further attempts by the pilot of VH-EEF and Brisbane FSU to contact VH-CLU were unsuccessful. The wreckage of the aircraft was later located about 800 metres to the west of the aerodrome. The aircraft had struck trees while heading in a direction aligned with runway 14 but displaced to the west of the runway. It had been destroyed as a result of the impact forces. Witnesses reported that when VH-CLU arrived at Dysart it was not raining, however, low cloud was present. The aircraft was observed to complete three orbits of the aerodrome and at times during these orbits it was obscured by cloud. Both occupants were killed.
Probable cause:
The only fault found with the aircraft during the investigation was a failed fuel pump on the right engine. It was established that the right engine was operating on impact and the failure of the fuel pump is not considered to have substantially affected the operation of the aircraft. The reason the aircraft crashed was not established.
Significant Factors:
1. Low cloud was present at Dysart for the arrival of VH-CLU.
2. The runway lighting had not been illuminated by the time VH-CLU arrived overhead the aerodrome.
3. The pilot attempted to hold in the vicinity of the aerodrome at low level, at night and in marginal weather conditions.
Final Report:

Crash of a Cessna 411 in Brisbane: 5 killed

Date & Time: Jan 5, 1982 at 1201 LT
Type of aircraft:
Operator:
Registration:
VH-AYE
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Brisbane - Brisbane
MSN:
411-0288
YOM:
1969
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2128
Captain / Total hours on type:
302.00
Aircraft flight hours:
4500
Circumstances:
At 1201 EST, shortly after taking off from Runway 10L at Archerfield Airport, the airplane crashed into an annex attached to a Thiess Contractors workshop located in Kerry Road, Archerfield. The accident site was 455 metres east-north-east from the departure end of the runway. The pilot and four workmen taking their lunch break in the annex were killed. The aircraft and the annex were destroyed by impact forces and the following explosion and fire. The accident occurred during a test flight following corrective maintenance. The aircraft had completed a periodic inspection on 23 December 1981 but, during the next 10 days, a problem was experienced with the control of the left hand propeller. Following maintenance on 4 January to rectify the problem, the pilot elected to test fly the aircraft prior to its intended use for endorsement training at 1500 hours on the day of the accident.
Probable cause:
The cause of the accident was that following a reduction of power from the left engine, the pilot failed to maintain flying speed. The cause of the reduction of power was not determined. The accident may have been avoided if the pilot had employed the correct procedures following a reduction of power from the left hand engine.
Final Report: