Crash of a Piper PA-46-310P Malibu near Narrabri

Date & Time: Jun 12, 2014 at 1630 LT
Operator:
Registration:
VH-TSV
Flight Phase:
Survivors:
Yes
Schedule:
Dubbo – Sunshine Coast
MSN:
46-8408022
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 12 June 2014, at about 1530 Eastern Standard Time (EST), a Piper PA-46 aircraft, registered VH-TSV, departed Dubbo, New South Wales for a private flight to the Sunshine Coast, Queensland with a pilot and one passenger on board. The planned route was to track via Moree and Toowoomba at 13,500 ft above mean sea level (AMSL). The pilot had operated the aircraft from Sunshine Coast to Lightning Ridge, Brewarrina and Dubbo earlier that day and reported that all engine indications were normal on those flights. About 1 hour after departing Dubbo, when about 26 NM south of Narrabri, at about 13,500 ft AMSL, the pilot observed the engine manifold pressure gauge indicating 25 inches Hg, when the throttle position selected would normally have produced about 28 inches Hg. The pilot selected the alternate air1 which did not result in any increase in power. He then elected to descend to 10,000 ft, and at that power setting when normally the engine would have produced about 29 inches Hg, the gauge still indicated only about 25 inches Hg. He turned the aircraft towards Narrabri in an attempt to fly clear of the Pilliga State Forest. The pilot assessed that the aircraft had a partial engine failure and performed troubleshooting checks. As the aircraft descended through about 8,000 ft, he observed the oil pressure gauge indicating decreasing pressure. When passing about 6,500 ft, the oil pressure gauge indicated zero and the pilot heard two loud bangs and observed the cowling lift momentarily from above the engine. The passenger observed a puff of smoke emanating from the engine and momentarily a small amount of smoke in the cockpit. The pilot established the aircraft in a glide at about 90 kt, secured the engine and completed the emergency checklist. He broadcast a ‘Mayday’ 2 call on Brisbane Centre radio frequency advising of an engine failure and forced landing. The pilot looked for a clear area below in which to conduct a forced landing and also requested the passenger to assist in identifying any cleared areas suitable to land. Both only identified heavily treed areas. The pilot extended the landing gear and selected 10º of flap and, when at about 1,000 ft, the pilot shut the fuel off, deployed the emergency beacon then switched off the electrical system. As the aircraft entered the tree tops, he flared to stall3 the aircraft. On impact, the pilot was seriously injured and lost consciousness. The passenger reported the wings impacted with trees and the aircraft slid about 10 m before coming to rest. The passenger checked for any evidence of fuel leak or fire and administered basic first aid to the pilot. The aircraft sustained substantial damage.
Final Report:

Crash of a Piper PA-31-310 Navajo C in Aldinga

Date & Time: Jan 29, 2014 at 1132 LT
Type of aircraft:
Operator:
Registration:
VH-OFF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Aldinga - Kangaroo Island
MSN:
31-7812064
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 29 January 2014, at about 1100 Central Daylight-savings Time, the pilot prepared a Piper PA-31 aircraft, registered VHOFF, for a private flight from Aldinga aeroplane landing area (ALA) to Kangaroo Island, South Australia. To check fuel quantities, the pilot entered the cockpit, turned on the master switch and placed the left and right fuel selectors onto the main tank (inboard) position. The gauge for each tank showed just under half full. He then placed each fuel selector onto the auxiliary (outboard) tank position, where the gauge indicated the right and left auxiliary tanks were each about a quarter full. He did not return the selectors to the main tanks. He estimated that refuelling the main tanks would allow sufficient fuel for the flight with over an hour in reserve. He exited the aircraft while it was refuelled and continued preparing for the flight. Once refuelling was completed, the pilot conducted a pre-flight inspection, and finished loading the aircraft. The pilot and passenger then boarded. The pilot was familiar with Aldinga ALA, which is a non-controlled airport. At uncontrolled airports, unless a restriction or preference is listed for a certain runway in either the Airservices en route supplement Australia (ERSA), or other relevant publications, selection of the runway is the responsibility of the pilot. Operational considerations such as wind direction, other traffic, runway surface and length, performance requirements for the aircraft on that day, and suitable emergency landing areas in the event of an aircraft malfunction are all taken into consideration. On this day, the pilot assessed the wind to be favoring runway 14, which already had an aircraft in the circuit intending to land. However, he decided to use runway 03 due to the availability of a landing area in case of an emergency. He then completed a full run-up check of the engines, propellers and magnetos prior to lining up for departure. The pilot reported that all of the pre-take-off checks were normal. Once the aircraft landing on runway 14 was clear of the runway, the pilot went through his usual memory checklist prior to take-off. He scanned and crosschecked the flight and panel instruments, power quadrant settings and trims, but did not complete his usual final check, which was to reach down with his right hand and confirm that the fuel selector levers were on the main tanks. After broadcasting on the common traffic advisory frequency (CTAF) he commenced the take-off. At the appropriate speed, he rotated the aircraft as it passed the intersection of the 14 and 03 runways. Almost immediately both engines began surging, there was a loss of power, the power gauges fluctuated and the aircraft yawed from side to side. Due to the surging, fluctuating gauges and aircraft yaw, the pilot found it difficult to identify what he thought was a non-performing engine. He reported there were no warning lights so he retracted the landing gear, with the intent of getting the aircraft to attain a positive rate of climb, so he could trouble shoot further at a safe altitude. When a little over 50 ft above ground level (AGL), he realized the aircraft was not performing sufficiently, so he selected a suitable landing area. He focused on maintaining a safe airspeed and landed straight ahead. The aircraft touched down and slid about another 75-100 metres before coming to rest. The impact marks of the propellers suggest the aircraft touched the ground facing north-easterly and rotated to the north-west prior to stopping. The pilot turned off the master switch and both he and the passenger exited the aircraft. After a few minutes he re-entered the cockpit and completed the shutdown. Police and fire service attended shortly after the accident.
Probable cause:
Engine malfunction due to fuel starvation.
Final Report:

Crash of a De Havilland DH.84 Dragon near Borumba Dam: 6 killed

Date & Time: Oct 1, 2012 at 1413 LT
Type of aircraft:
Operator:
Registration:
VH-UXG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Monto - Caboolture
MSN:
6077
YOM:
1934
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
1134
Captain / Total hours on type:
662.00
Circumstances:
At about 1107 Eastern Standard Time on 01OCT2012, a de Havilland Aircraft Pty Ltd DH-84 Dragon, registered VH-UXG (UXG), took off from Monto on a private flight to Caboolture, Queensland under the visual flight rules (VFR). On board the aircraft were the pilot/owner and five passengers. The weather conditions on departure were reported to include a light south-easterly wind with a high overcast and good visibility. Sometime after about 1230, the aircraft was seen near Tansey, about 150 km north-west of Caboolture on the direct track from Monto to Caboolture. The aircraft was reported flying in a south-easterly direction at the time, at an estimated height of 3,000 ft and in fine but overcast conditions. At 1315, the pilot contacted Brisbane Radar air traffic control (ATC) and advised that the aircraft’s position was about 37 NM (69 km) north of Caboolture and requested navigation assistance. At 1318, the pilot advised ATC that the aircraft was in ‘full cloud’. For most of the remainder of the flight, the pilot and ATC exchanged communications, at times relayed through a commercial flight and a rescue flight in the area due to the limited ATC radio coverage in the area at low altitude. At about 1320, a friend of one of the aircraft’s passengers received a telephone call from the passenger to say that she was in an aircraft and that they were ‘lost in a cloud’ and kept losing altitude. Witnesses in the Borumba Dam, Imbil and Kandanga areas 70 to 80 km north-north-west of Caboolture later reported that they heard and briefly saw the aircraft flying in and out of low cloud between about 1315 and 1415. At 1348, the pilot advised ATC that the aircraft had about an hour’s endurance remaining. The pilot’s last recorded transmission was at 1404. A search for the aircraft was coordinated by Australian Search and Rescue (AusSAR). The aircraft wreckage was located on 3 October 2012, about 87 km north-west of Caboolture on the northern side of a steep, densely wooded ridge about 500 m above mean sea level. The Australian Transport Safety Bureau (ATSB) later determined that the aircraft probably impacted terrain at about 1421 on 01OCT2012. Preliminary analysis indicated that the aircraft collided with trees and terrain at a moderate to high speed, with a left angle of bank. The aircraft’s direction of travel at impact was toward the south-south-west.
Probable cause:
From the evidence available, the following findings are made with respect to the visual flight rules into instrument meteorological conditions accident involving de Havilland Aircraft Pty Ltd DH-84 Dragon, registered VH-UXG, that occurred 36 km south-west of Gympie, Queensland, on 1 October 2012. These findings should not be read as apportioning blame or liability to any particular organisation or individual. Safety issues, or system problems, are highlighted in bold to emphasize their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.
Contributing factors:
- The pilot unintentionally entered instrument meteorological conditions and was unable to reattain and maintain visual conditions.
- It is likely that the pilot became spatially disoriented and lost control due to a combination of factors such as the absence of a visible horizon, cumulative workload, stress and/or distraction.
Other factors that increased risk:
- Though it probably did not have a significant bearing on the event, the aircraft was almost certainly above its maximum take-off weight (MTOW) on take-off, and around the MTOW at the time of the accident.
- Though airborne search and rescue service providers were regularly tasked to provide assistance to pilots in distress, there was limited specific guidance on the conduct of such assistance. Other findings:
- The aircraft wreckage was not located for 2 days as the search was hindered by difficult local weather conditions and terrain, and the cessation of the aircraft’s emergency beacon due to impact damage.
Final Report:

Crash of a Rockwell Shrike Commander 500S off Horn Island: 1 killed

Date & Time: Feb 24, 2011 at 0800 LT
Operator:
Registration:
VH-WZU
Flight Type:
Survivors:
No
Schedule:
Cairns - Horn Island
MSN:
3060
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4154
Captain / Total hours on type:
209.00
Aircraft flight hours:
17545
Circumstances:
At 0445 Eastern Standard Time on 24 February 2011, the pilot of an Aero Commander 500S, registered VH-WZU, commenced a freight charter flight from Cairns to Horn Island, Queensland under the instrument flight rules. The aircraft arrived in the Horn Island area at about 0720 and the pilot advised air traffic control that he intended holding east of the island due to low cloud and rain. At about 0750 he advised pilots in the area that he was north of Horn Island and was intending to commence a visual approach. When the aircraft did not arrive a search was commenced but the pilot and aircraft were not found. On about 10 October 2011, the wreckage was located on the seabed about 26 km north-north-west of Horn Island.
Probable cause:
The ATSB found that the aircraft had not broken up in flight and that it impacted the water at a relatively low speed and a near wings-level attitude, consistent with it being under control at impact. It is likely that the pilot encountered rain and reduced visibility when manoeuvring to commence a visual approach. However, there was insufficient evidence available to determine why the aircraft impacted the water.
Several aspects of the flight increased risk. The pilot had less than 4 hours sleep during the night before the flight and the operator did not have any procedures or guidance in place to minimize the fatigue risk associated with early starts. In addition, the pilot, who was also the operator’s chief pilot, had either not met the recency requirements or did not have an endorsement to conduct the types of instrument approaches available at Horn Island and several other locations frequently used by the operator.
Final Report:

Crash of a Fletcher FU-24A-954 in Wynella Station: 1 killed

Date & Time: Dec 20, 2010 at 1700 LT
Type of aircraft:
Registration:
VH-FNM
Survivors:
No
Schedule:
Wynella Station - Wynella Station
MSN:
263
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5815
Circumstances:
On 20 December 2010, the owner/pilot of a Pacific Aerospace Corporation FU-24-954 Fletcher aircraft, registered VH-FNM, was conducting aerial spreading of urea fertilizer at Wynella Station; a property 40 km south-south-west of Dirranbandi, Queensland. At about 1650 Eastern Standard Time, the pilot was returning to the landing strip after the completion of an application run. The aircraft impacted the terrain, and the pilot was fatally injured.
Probable cause:
Examination of the accident site indicated that the aircraft’s engine was delivering power at the time of impact. Wreckage examination did not reveal evidence of any defect or mechanical failure that would have contributed to the event. Although the post-mortem report on the pilot noted that he had significant coronary atherosclerosis, there was insufficient information available to determine whether pilot incapacitation was involved in the accident. The investigation did not identify any organisational or systemic issues that might adversely affect the future safety of aviation
operations.
Final Report:

Crash of a Gippsland GA8 Airvan in Lady Barron

Date & Time: Oct 15, 2010 at 1715 LT
Type of aircraft:
Operator:
Registration:
VH-DQP
Survivors:
Yes
Site:
Schedule:
Lady Barron - Bridport
MSN:
GA8-05-075
YOM:
2005
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2590
Captain / Total hours on type:
1355.00
Circumstances:
The pilot was conducting a charter flight from Lady Barron, Flinders Island to Bridport, Tasmania with six passengers on board. The aircraft departed Lady Barron Aerodrome at about 1700 Australian Eastern Daylight-saving Time and entered instrument meteorological conditions (IMC) several minutes afterwards while climbing to the intended cruising altitude of about 1,500 ft. The pilot did not hold a command instrument rating and the aircraft was not equipped for flight in IMC. He attempted to turn the aircraft to return to Lady Barron Aerodrome but became lost, steering instead towards high ground in the Strzelecki National Park in the south-east of Flinders Island. At about 1715, the aircraft exited cloud in the Strzelecki National Park, very close to the ground. The pilot turned to the left, entering a small valley in which he could neither turn the aircraft nor out climb the terrain. He elected to slow the aircraft to its stalling speed for a forced landing and, moments later, it impacted the tree tops and then the ground. The first passenger to exit the aircraft used the aircraft fire extinguisher to put out a small fire that had begun beneath the engine. The other passengers and the pilot then exited the aircraft safely. One passenger was slightly injured during the impact; the pilot and other passengers were uninjured. During the night, all of the occupants of the aircraft were rescued by helicopter and taken to the hospital in Whitemark, Flinders Island.
Probable cause:
Contributing safety factors:
• The weather was marginal for flight under the visual flight rules, with broken cloud forecast down to 500 ft above mean sea level in the area.
• The pilot, who did not hold a command instrument rating, entered instrument meteorological conditions because he was adhering to an un-written operator rule not to fly below 1,000 ft above ground level.
• The pilot became lost in cloud and flew the aircraft towards the Mt Strzelecki Range, exiting the cloud in very close proximity to the terrain.
• The aircraft exited the cloud in a small valley, within which the pilot could neither turn round nor out-climb the terrain.
Other key findings:
• The aircraft exited cloud before impacting terrain and with sufficient time for the pilot to execute a forced landing.
• The design of the aircraft’s seats, and the provision to passengers in the GA-8 Airvan of three-point automotive-type restraint harnesses with inertia reel shoulder straps contributed to the passengers’ survival, almost without injury.
Final Report:

Crash of a Gippsland GA-8 Airvan in Orange

Date & Time: Jul 6, 2010 at 1745 LT
Type of aircraft:
Operator:
Registration:
VH-YBH
Flight Type:
Survivors:
Yes
Schedule:
Parkes - Orange
MSN:
GA8-08-131
YOM:
2008
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot was performing a cargo flight from Parkes to Orange, New South Wales. On final approach, the single engine aircraft was too low and impacted the roof of a metal hangar located near the runway threshold. The aircraft stalled and struck the runway surface. Upon impact, the nose gear was torn off. Out of control, the aircraft veered off runway and eventually collided with a metal hangar under construction. While the pilot was injured, the aircraft was destroyed.

Crash of a Piper PA-31 Cheyenne in Bankstown: 2 killed

Date & Time: Jun 15, 2010 at 0805 LT
Type of aircraft:
Operator:
Registration:
VH-PGW
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Bankstown - Brisbane - Albury
MSN:
31-8414036
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2435
Captain / Total hours on type:
779.00
Aircraft flight hours:
6266
Circumstances:
The twin engine aircraft, with a pilot and a flight nurse on board, was being operated by Skymaster Air Services under the instrument flight rules (IFR) on a flight from Bankstown Airport, New South Wales (NSW) to Archerfield Airport, Queensland. The aircraft was being positioned to Archerfield for a medical patient transfer flight from Archerfield to Albury, NSW. The aircraft departed Bankstown at 0740 Eastern Standard Time. At 0752, the pilot reported to air traffic control (ATC) that he was turning the aircraft around as he was having ‘a few problems. At about 0806, the aircraft collided with a powerline support pole located on the eastern side of the intersection of Sackville Street and Canley Vale Road, Canley Vale, NSW. The pilot and flight nurse sustained fatal injuries and the aircraft was destroyed by impact damage and a post-impact fire.
Probable cause:
Contributing safety factors:
• While the aircraft was climbing to 9,000 feet the right engine sustained a power problem and the pilot subsequently shut down that engine.
• Following the shutdown of the right engine, the aircraft's descent profile was not optimized for one engine inoperative flight.
• The pilot conducted a descent towards Bankstown Airport that was consistent with a normal arrival profile without first verifying that the aircraft was capable of achieving adequate performance with one engine inoperative.
• Following the engine problem, the aircraft's flightpath and the pilot’s communication with air traffic control indicated that the pilot's situation awareness was less than optimal.
• The aircraft collided with a powerline support pole on the eastern side of the intersection of Sackville Street and Canley Vale Road, Canley Vale, about 6 km north-west of Bankstown Airport.
Other safety factors:
• The pilot did not broadcast a PAN following the engine shutdown and did not provide air traffic control with further information about the nature of the problem in order for the controller to positively establish the severity of the situation.
• Section 4 of Civil Aviation Advisory Publication (CAAP) 5.23-2(0), Multi-engine Aeroplane Operations and Training of July 2007 did not contain sufficient guidance material to support the flight standard in Appendix A subsection 1.2 of the CAAP relating to Engine Failure in the Cruise. [Minor safety issue]
Other key finding:
• Given the pilot’s extensive experience and testing in the PA-31 aircraft type, and subsequent endorsement training on a high performance turboprop multi-engine aircraft since the issue by CASA in 2008 of a safety alert in respect of the pilot’s PA-31 endorsement, it was unlikely that any deficiencies in that endorsement training contributed to the accident.
Final Report:

Crash of an Embraer EMB-120ER Brasília in Darwin: 2 killed

Date & Time: Mar 22, 2010 at 1009 LT
Type of aircraft:
Operator:
Registration:
VH-ANB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Darwin - Darwin
MSN:
120-116
YOM:
1988
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8217
Captain / Total hours on type:
3749.00
Copilot / Total flying hours:
5664
Copilot / Total hours on type:
3085
Aircraft flight hours:
32799
Aircraft flight cycles:
33700
Circumstances:
Aircraft crashed moments after takeoff from runway 29 at Darwin Airport, Northern Territory, fatally injuring both pilots. The flight was for the purpose of revalidating the command instrument rating of the pilot under check and was under the command of a training and checking captain, who occupied the copilot’s seat. The takeoff included a simulated engine failure. Data from the aircraft’s flight recorders was used to establish the circumstances leading to the accident and showed that the pilot in command (PIC) retarded the left power lever to flight idle to simulate an engine failure. That introduced a simulated failure of the left engine and propeller autofeathering system. The increased drag from the ‘windmilling’ propeller increased the control forces required to maintain the aircraft’s flightpath. The pilot under check allowed the speed to decrease and the aircraft to bank toward the inoperative engine. Additionally, he increased power on the right engine, and engaged the yaw damper in an attempt to stabilize the aircraft’s flight. Those actions increased his workload and made control of the aircraft more difficult. The PIC did not restore power to the left engine to discontinue the manoeuvre. The few seconds available before the aircraft became uncontrollable were insufficient to allow ‘trouble shooting’ and deliberation before resolving the situation.
Probable cause:
• The pilot in command initiated a simulated left engine failure just after becoming airborne and at a speed that did not allow adequate margin for error.
• The pilot in command simulated a failure of the left engine by selecting flight idle instead of zero thrust, thereby simulating a simultaneous failure of the left engine and its propeller autofeather system, instead of a failure of the engine alone.
• The pilot under check operated the aircraft at a speed and attitude (bank angle) that when uncorrected, resulted in a loss of control.
• The pilot under check increased his workload by increasing torque on the right engine and selecting the yaw damper.
• The pilot in command probably became preoccupied and did not abandon the simulated engine failure after the heading and speed tolerance for the manoeuvre were exceeded and before control of the aircraft was lost.
Final Report:

Crash of a Cessna 208B Grand Caravan in Beagle Bay

Date & Time: Jan 14, 2010 at 0645 LT
Type of aircraft:
Operator:
Registration:
VH-NTQ
Flight Type:
Survivors:
Yes
Schedule:
Broome - Koolan Island
MSN:
208B-0635
YOM:
1997
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Broome on a charter flight to Koolan Island, WA. At about 0645 Western Standard Time1, when the aircraft was at an altitude of about 9,500 feet, the pilot noticed a drop in the engine torque indication with a corresponding drop in the engine oil pressure indication. The pilot increased the power lever setting but the engine torque and oil indications continued to reduce, all other engine indications were normal. During an interview with the Australian Transport Safety Bureau (ATSB) the pilot stated that he felt a power loss associated with the drop in indicated engine torque. The pilot diverted to the nearest airstrip, which was Beagle Bay, WA. He stated that the low oil pressure warning light illuminated so he shut the engine down and prepared for an emergency landing. The pilot reported that on the final approach to the airstrip he realized that the aircraft was too high and its airspeed was too fast. The aircraft touched down about mid way along the runway and overran the end of the runway by about 200 metres. The aircraft impacted a mound of dirt, coming to rest upside down. The pilot, who was the only occupant sustained minor injuries. Examination of the aircraft by a third party and inspection of the photographs taken of the accident site, revealed that the engine, left main gear and nose gear had separated from the airframe during the accident sequence. There was a significant amount of oil present on the underside of the aircraft, indicating that the oil had leaked from the engine during operation. The
engine was removed from the accident site as an assembly by a third party. The propeller was removed and the engine was shipped to an engine overhaul facility where a disassembly and
examination was conducted under the supervision of the ATSB.
Probable cause:
From the evidence available it was evident that the engine had a substantial in-flight oil leak, which necessitated the in-flight shut down of the engine and a diversion to the nearest available airstrip. The accident damage to the engine in the area of the apparent oil leak precluded a conclusive finding as to the source of the leak. Although the detailed examination of the oil tube attachment lug fracture surfaces was inconclusive, the oil tube remained the most likely source of the oil leak. Evidence from other oil tube failures indicated that significant vibratory loading can cause the oil tube attachment lugs to fracture in the manner observed in the oil tube fitted to VH-NTQ. There was no evidence that the transfer tube was subjected to vibration from a compressor turbine or power turbine blade failure or of an incorrectly fitted engine mount. There was also no evidence of a pre-accident defect that would have caused a reduction in actual engine torque.
Final Report: