Crash of a Fletcher FU-24-A4 near Dunedoo: 1 killed

Date & Time: Oct 30, 1996 at 1000 LT
Type of aircraft:
Operator:
Registration:
VH-BBG
Flight Phase:
Survivors:
No
Schedule:
Dunedoo - Dunedoo
MSN:
141
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7200
Captain / Total hours on type:
28.00
Circumstances:
The pilot had arrived at the property to commence spraying operations on the day before the accident, and had been provided with a map of the area by the property owner. In addition, the property owner briefed the pilot on the location of relevant powerlines and other obstructions. However, the pilot did not carry out any spraying on that day, but instead flew the aircraft to Scone, in order to have a minor engine problem rectified. He then flew to Mudgee where the aircraft remained overnight. The pilot returned to the area the next morning, arriving on site at about 0645 ESuT. After spraying approximately 175 acres on an adjoining farm, he commenced an aerial inspection of the next property to be treated, but declined an offer by the property owner to accompany him in the aircraft so the property boundaries and powerlines could be pointed out. The aircraft was seen to make three passes over the area before it descended in an easterly direction, toward a crop of barley. A gentle rise, which included a dam bank located at the corner of the crop, had to be negotiated in order for the pilot to position the aircraft at the correct operating height for the swath run. A spurline, suspended over the crop and running in a northerly direction, was located a further 40 m beyond the dam. A witness reported that the aircraft had appeared to be maintaining level flight, and had commenced spraying, when it struck the spurline, then impacted heavily with the ground and overturned, fatally injuring the pilot. The weather in the area at the time of the accident was reported as fine, with light winds. The aircraft struck a three-wire spurline which ran in a northerly direction over the crop, at right angles to its flight path. The line spanned 165 m from the main powerline to the first spurline pole, located about 100 m from a house and to the left of the flight path. A number of large trees nearer to the house provided a backdrop to the spurline pole. A strainer wire stemming from the main powerline was positioned some 92 m further on in the direction of the intended flight path. It was about 10 m in length and ran parallel to the spurline. The strainer wire passed over a road and was attached to a support pole located one metre from the edge of the barley crop. The pilot had commenced the first swathe run by flying in an easterly direction, towards distant rising ground which was cloaked in shadow, whilst the powerline in the foreground was set against this backdrop.
Probable cause:
The following factors were reported:
1. The pilot had limited recent flying experience.
2. The pilot had limited experience on the aircraft type, particularly with regard to low-level spraying operations, prior to the accident.
3. The performance of the pilot may have been impared by the effects of a medical condition he was suffering from.
4. The location of the spurline was difficult to see and may have been confused with an apparent powerline, further along the intended flight path.
5. The aircraft was not fitted with any form of wire deflector or cutter.
6. The aircraft provided limited structural rollover protection for the pilot during the accident sequence.
Final Report:

Crash of a Britten-Norman BN-2A-21 Islander in Coolangatta

Date & Time: Apr 7, 1996 at 2138 LT
Type of aircraft:
Registration:
VH-HIA
Survivors:
Yes
Schedule:
Tangalooma – Coolangatta
MSN:
415
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
881
Captain / Total hours on type:
177.00
Circumstances:
The aircraft was the third in a stream of five company aircraft departing the Tangalooma Resort airstrip at two-minute intervals on a clear moonlit evening. Following a routine departure at 2105 EST, the aircraft was climbed to 3,000 ft for the flight back to Coolangatta. Early in the cruise phase of the flight, the pilot found that the fourth aircraft was catching up to his and he elected to descend to 2,000 ft to ensure continued separation. At 2127 EST, the pilot reported to Coolangatta Approach Control that the aircraft had severe problems, but did not inform the controller of the nature of his emergency. However, the controller activated the airport emergency procedures when he observed on his radar display that the aircraft was losing altitude. The pilot had his second VHF radio transceiver tuned to his company frequency, and was answering transmissions received from other company pilots on this frequency while transmitting on the Coolangatta Approach frequency. The pilot later said that after the aircraft passed the seaway at Southport, the right engine surged, which resulted in the aircraft yawing. After he switch the electric fuel pump to "on", the symptoms disappeared. About a minute later he switched the pump off, then on again. He said that when the engine began surging again, he shut the engine down, feathering the propeller. Left engine power was increased and the aircraft maintained 1,500 ft in level flight. He switched the left engine's fuel supply to the right main tank, believing that this action would ensure supply from both main fuel tanks. The pilot said that after the aircraft passed Burleigh Heads, many things appeared to go wrong at once. The left engine began to splutter and did not respond to the throttle. He recalled attempting to restart the right engine. This proved to be unsuccessful. As the descent continued he planned to land on a beach. The pilot selected a stretch of beach for a forced landing. During late final approach, aided by bright moonlight, he noticed that any overrun would take the aircraft into a crowded car park. He changed his aim point to the stretch of beach south of the Currumbin Lifesavers Clubhouse. Following the flare for landing, the right wing struck a low rocky outcrop and the aircraft crashed into the surf. The entire wing assembly separated from the fuselage, which came to rest on its left side. Some of the nine passengers, and the pilot, escaped from the semi-submerged fuselage while bystanders rescued others.
Probable cause:
The following findings were reported:
1. The pilot shut down an engine following surging but did not feather the propeller.
2. The aircraft was not flown at (or near) its best single-engine performance speed after the right engine was shut down.
Final Report:

Crash of a Beechcraft 65-B80 Queen Air in Cannington

Date & Time: Feb 12, 1996 at 1004 LT
Type of aircraft:
Registration:
VH-PCQ
Flight Phase:
Survivors:
Yes
Schedule:
Cannington – Townsville
MSN:
LD-495
YOM:
1975
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3758
Captain / Total hours on type:
1023.00
Copilot / Total flying hours:
634
Copilot / Total hours on type:
276
Circumstances:
The aircraft was engaged on a charter flight for the BHP Cannington mine, and departed from Townsville at 0630 EST. The flight was uneventful and the aircraft landed at Cannington at 0840. The aircraft was refuelled and at about 0945 seven passengers and baggage were loaded. The aircraft was started and taxied for runway 36. During this time the necessary checks were completed. The takeoff was commenced, and after the aircraft became airborne and was accelerating with a positive rate of climb, the landing gear was selected up. While the gear was still in transit, there was a sudden power loss from the left engine. The pilot described a simultaneous height loss, roll, pitch, and yaw accompanied by a sound similar to a buzz saw from the left engine. The pilot immediately recognised that the left engine had failed and attempted to maintain speed and directional control. Power was reduced on the right engine to maintain directional control, and it was the pilot's intention to land the aircraft with gear retracted beyond the end of the runway. However, the left wingtip struck a steel fence post, and this spun the aircraft to the left. The aircraft struck a low earth bank while travelling sideways and rearwards. When the aircraft came to rest, all windows were obscured and the pilot believed the aircraft was on fire. The pilot tried unsuccessfully to open the main cabin door, and the passengers were then evacuated through the emergency exit.
Probable cause:
The following findings were reported:
- The retaining bolts for the propeller gearbox stationary gear assembly failed when the aircraft had just become airborne.
- The pilot was unable to maintain directional control and landed the aircraft with landing gear retracted.
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 Gippsland GA8 Airvan in Latrobe Valley

Date & Time: Feb 7, 1996 at 1845 LT
Type of aircraft:
Operator:
Registration:
VH-PTR
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Latrobe Valley - Latrobe Valley
MSN:
GA8-0001
YOM:
1995
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6500
Captain / Total hours on type:
100.00
Circumstances:
The prototype GA-8 aircraft was undertaking test flying from the manufacturer's facility at the Latrobe Valley airfield. The test flying was scheduled by the designer under the provisions of a permit to fly approved by the Civil Aviation Safety Authority. For a series of spin tests the aircraft was fitted with fixed and jettisonable ballast, a jettisonable pilot's door, and a tail mounted anti-spin parachute attached to a long lanyard. On this flight the aircraft was set up at 9,000 feet above ground level with full power, flaps fully down, an extreme aft centre of gravity (C of G) and maximum all up weight. The test pilot, who was the only occupant, applied full left rudder and full right aileron to initiate a spin. After the aircraft entered a spin to the left the pilot applied standard control inputs to effect a recovery to normal flight. The aircraft did not respond and at 6,500 feet, 13 seconds after the spin commenced, the pilot jettisoned the ballast and deployed the anti-spin parachute. The aircraft still did not respond and at about 32 seconds into the spin, at 5,200 feet, the pilot initiated release of the jettisonable door, released his harness, baled out, and was clear of the aircraft as it passed through 3,600 feet. At 1,800 feet the aircraft was observed to stop spinning. Fifty seconds after the commencement of the spin, the aircraft dived into the ground and was destroyed. The pilot sustained minor injuries during his landing.
Probable cause:
This was a prototype aircraft and some deficiencies and/or problems during testing are to be expected. With this particular aircraft the fact that the inadequate rudder hinge moment was masked throughout flight testing meant that the inadequate rudder performance during critical spin recovery was not clearly detected until it combined with other factors to become critical. These other factors included an ineffective anti-spin parachute, extensive blanking of the fin and rudder, and flight at the extremes of the weight and C of G envelope. It is not known what , if any, effect the previous rerigging of the elevator controls had on this flight.
The following factors were reported:
1. The rudder and fin effectiveness was inadequate for the spin test being undertaken.
2. The anti-spin protection systems were ineffective.
3. The aircraft was not able to be recovered from an intentional spin.
Final Report:

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

Date & Time: Dec 12, 1995 at 0918 LT
Operator:
Registration:
VH-UJP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Horn Island - Horn Island
MSN:
500-3074
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:
11740
Captain / Total hours on type:
119.00
Circumstances:
At approximately 0910 EST, the aircraft took off from runway 32 at Horn Island and commenced a normal climb. Shortly after, it adopted a nose-high attitude and commenced a wingover type manoeuvre to the right. Witnesses described the aircraft as being in a nose-low attitude, and at a height of approximately 600 ft to 700 ft above ground level after the completion of this manoeuvre. It then abruptly adopted a level attitude and rapidly entered a spin to the left. Witnesses on the ground reported that at approximately the same time as the aircraft entered the spin, engine power became asymmetric, with the right engine continuing to deliver considerable power. The aircraft continued to descend in a fully developed flat spin, with no observed signs of an attempt to recover. The impact was heard shortly after the aircraft descended behind vegetation to the north-west of the aerodrome. The accident was reported to Flight Service by radio at 0918. The wreckage was located on a beach approximately 2 km to the north-west of the aerodrome. The aircraft was destroyed by impact forces and the pilot sustained fatal injuries.
Probable cause:
The following findings were reported:
1. The pilot held a valid pilot licence and medical certificate.
2. The pilot was endorsed on the aircraft type.
3. The aircraft entered a flat spin to the left with no reported signs of an attempt to recover.
4. The aircraft struck the ground whilst established in a flat left spin.
5. The right engine was producing considerable power prior to impact.
6. Indications were that the left engine was producing little or no power. Its propeller was in the feathered position prior to impact.
7. No evidence was found to indicate a malfunction or pre-existing defect with the aircraft or its systems which may have affected normal operation during this flight.
8. No evidence was found to indicate pilot incapacitation as the result of a medical condition or the presence of alcohol or drugs.
9. The pilot's behaviour on the morning of the accident was not consistent with what was generally accepted to be a thorough and professional attitude to aviation.
Final Report:

Crash of a Partenavia P.68B in Tangalooma

Date & Time: Nov 22, 1995 at 2110 LT
Type of aircraft:
Registration:
VH-TLQ
Flight Phase:
Survivors:
Yes
Schedule:
Tangalooma – Coolangatta
MSN:
33
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
905
Captain / Total hours on type:
57.00
Circumstances:
The aircraft was the second to take off in a stream of six on a night flight from the Tangalooma Resort strip to Coolangatta aerodrome. Shortly after takeoff it struck the ground, nosed over and was consumed by a fuel-fed fire. The take-off run appeared normal but the initial climb was shallow according to the witnesses, some of whom were pilots waiting their turn to take off. At about 150 ft above ground level the aircraft entered a descent which continued until ground impact, 164 m beyond the departure end of the strip. The nose gear collapsed at impact but the aircraft remained upright and skidded along the ground on its main gear and front fuselage. It traversed a low sand dune, fell 10 ft to the beach and overturned. The aircraft came to rest 112 m beyond the first ground contact. All four passengers were able to evacuate the aircraft which had started to burn. The pilot was rescued by her passengers.
Probable cause:
The following factors were reported:
1. The takeoff direction was dark and had no visible horizon.
2. The elevator trim was not set for takeoff.
3. The elevator load on takeoff was high.
4. The pilot did not monitor the aircraft attitude after lift-off.
5. The flap was retracted in one movement, increasing the elevator load.
6. The pilot may have been affected by somatogravic illusion to the extent that she thought the climb attitude was adequate.
Final Report:

Crash of a Swearingen SA227AC Metro III in Tamworth: 2 killed

Date & Time: Sep 16, 1995 at 1957 LT
Type of aircraft:
Operator:
Registration:
VH-NEJ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tamworth - Tamworth
MSN:
AC-629B
YOM:
1985
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4132
Captain / Total hours on type:
1393.00
Copilot / Total flying hours:
1317
Copilot / Total hours on type:
1
Aircraft flight hours:
15105
Circumstances:
Two company pilots were undergoing first officer Metro III type-conversion flying training. Both had completed Metro III ground school training during the week before the accident. A company check-and-training pilot was to conduct the type conversions. This was his first duty period after 2 weeks leave. Before commencing leave, he had discussed the training with the chief pilot. This discussion concerned the general requirements for a co-pilot conversion course compared to a command pilot course but did not address specific sequences or techniques. The three pilots met at the airport at about 1530 EST on 16 September 1995. During the next 2 hours and 30 minutes approximately, the check-and-training pilot instructed the trainees in daily and pre-flight inspections, emergency equipment and procedures, and cockpit procedures and drills (including the actions to be completed in the event of an engine failure), as they related to the aircraft type. The briefing did not include detailed discussion of aircraft handling following engine failure on takeoff. The group began a meal break at 1800 and returned to the aircraft at about 1830 to begin the flying exercise. The check-and-training pilot was pilot in command for the flight and occupied the left cockpit seat. One trainee occupied the right (co-pilot) cockpit seat while the other probably occupied the front row passenger seat on the left side. This person had the use of a set of head-phones to listen to cockpit talk and radio calls. The aircraft departed Tamworth at 1852, some 40 minutes after last light. Witnesses described the night as very dark, with no moon. Under these conditions, the Tamworth city lighting, which extended to the east from about 2 km beyond the end of runway 12, was the only significant visual feature in the area. The co-pilot performed the takeoff, his first in the Metro III. For about the next 30 minutes, he completed various aircraft handling exercises including climbing, descending, turning (including steep turns), and engine handling. No asymmetric flight exercises were conducted. The check-and-training pilot then talked the co-pilot through an ILS approach to runway 30R with an overshoot and landing on runway 12L. The landing time was 1940. The aircraft had functioned normally throughout the flight. After clearing the runway, the aircraft held on a taxiway for 6 minutes, with engines running. During this period, the crew discussed the next flight which was to be flown by the same co-pilot. The check-and-training pilot stated that he was going to give the co-pilot a V1 cut. The co-pilot objected and then questioned the legality of night V1 cuts. The check-and-training pilot replied that the procedure was now legal because the company operations manual had been changed. The co-pilot made a further objection. The check-and-training pilot then said that they would continue for a Tamworth runway 30R VOR/DME approach and asked the co-pilot to brief him on this approach. The crew discussed the approach and the check-and-training pilot then requested taxi clearance. The aircraft was subsequently cleared to operate within a 15-NM radius of Tamworth below 5,000 ft. The crew then briefed for the runway 12L VOR/DME approach. The plan was to reconfigure the aircraft for normal two-engine operations after the V1 cut and then complete the approach. The crew completed the after-start checks, the taxi checks, and then the pre-take-off checks. The checks included the co-pilot calling for one-quarter flap and the check-and-training pilot responding that one-quarter flap had been selected. The crew briefed the take-off speeds as V1 = 100 kts, VR = 102 kts, V2 = 109 kts, and Vyse = 125 kts for the aircraft weight of 5,600 kg. Take-off torque was calculated as 88% and watermethanol injection was not required. The aircraft commenced the take-off roll at 1957.05. About 25 seconds after brakes release, the check-and-training pilot called 'V1', and less than 1 second later, 'rotate'. The aircraft became airborne at 1957.32. One second later, the check-and-training pilot reminded the co-pilot that the aircraft attitude should be 'just 10 degrees nose up'. After a further 3 seconds, the check-and-training pilot retarded the left engine power lever to the flight-idle position. Over the next 4 seconds, the recorded magnetic heading of the aircraft changed from 119 degrees to 129 degrees. The co-pilot and then the check-and-training pilot called that a positive rate of climb was indicated and the landing gear was selected up 15 seconds after the aircraft became airborne. The landing gear warning horn began to sound at approximately the same time. After 19 seconds airborne, and again after 30 seconds, the check-and-training pilot reminded the co-pilot to hold V2. Three seconds later, the check-and-training pilot said that the aircraft was descending. The landing gear warning horn ceased about 1 second later. By this time, the aircraft had gradually yawed left from heading 129 degrees, through the runway heading of 121 degrees, to 107 degrees. After being airborne for 35 seconds, the aircraft struck a tree approximately 350 m beyond, and 210 m left of, the upwind end of runway 12L. It then rolled rapidly left, severed power lines and struck other trees before colliding with the ground in an inverted attitude and sliding about 70 m. From the control tower, the aerodrome controller saw the aircraft become airborne. As it passed abeam the tower, the controller directed his attention away from the runway. A short time later, all lighting in the tower and on the airport failed and the controller noticed flames from an area to the north-east of the runway 30 threshold. Within about 30 seconds, when the emergency power supply had come on line, the controller attempted to establish radio contact with the aircraft. When no response was received, he initiated call-out of the emergency services.
Probable cause:
The following factors were reported:
1. There was no enabling legislative authority for AIP (OPS) para. 77.
2. CASA oversight, with respect to the company operations manual and specific guidance concerning night asymmetric operations, was inadequate.
3. The company decided to conduct V1 cuts at night during type-conversion training.
4. The check-and-training pilot was assigned a task for which he did not possess adequate experience, knowledge, or skills.
5. The check-and-training pilot gave the co-pilot a night V1 cut, a task which was inappropriate for the co-pilot's level of experience.
6. The performance of the aircraft during the flight was adversely affected by the period the landing gear remained extended after the simulated engine failure was initiated and by the control inputs of the co-pilot.
7. The check-and-training pilot did not recognise that the V1 cut exercise should be terminated and that he should take control of the aircraft.
Final Report:

Crash of an IAI-1124 Westwind in Alice Springs: 3 killed

Date & Time: Apr 27, 1995 at 1957 LT
Type of aircraft:
Operator:
Registration:
VH-AJS
Flight Type:
Survivors:
No
Schedule:
Darwin – Katherine – Alice Springs – Adélaïde – Sydney
MSN:
221
YOM:
1978
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
10108
Captain / Total hours on type:
2530.00
Copilot / Total flying hours:
3747
Copilot / Total hours on type:
85
Aircraft flight hours:
11508
Circumstances:
The aircraft was on a scheduled freight service from Darwin via Tindal, Alice Springs, and Adelaide to Sydney under the IFR. The flight from Darwin to Tindal was apparently normal, and the aircraft departed Tindal slightly ahead of schedule at 1834 CST. The pilot in command occupied the left cockpit seat. At 1925, the aircraft reported at position DOLPI (200 miles north of Alice Springs) Flight Level 330, to Melbourne Control. Another Westwind aircraft was en route Darwin–Alice Springs and was more than 40 miles ahead of VH-AJS. Information from the aircraft cockpit voice recording confirmed that the pilot in command was flying the aircraft. At about 1929, he began issuing instructions to the co-pilot to program the aircraft navigation system in preparation for a locator/NDB approach to Alice Springs. The pilot in command asked the co-pilot to enter an offset position into the area navigation (RNAV) system for an 11-mile final for runway 12. The co-pilot entered the bearing as 292 degrees Alice Springs. (This was the outbound bearing from Alice Springs NDB to Simpson’s Gap locator indicated on the locator/NDB approach chart.) The pilot in command stated that he had wanted the bearing with respect to the runway, 296 degrees, entered but said that the setting could be left as 292 degrees. He then instructed the co-pilot to set Alice Springs NDB frequency on ADF 1, Simpson’s Gap locator on ADF 2, and to preset the Temple Bar locator frequency on ADF 2 so that it could be selected as soon as the aircraft passed overhead Simpson’s Gap. He indicated his intention to descend to 4,300 feet until overhead Simpson’s Gap, and said that the co-pilot should then set 3,450 feet on the altitude alert selector. On passing Temple Bar, the co-pilot was to set 2,780 feet on the altitude alert selector which the pilot in command said would be used as the minimum for the approach. At 1940, the co-pilot contacted Adelaide Flight Service (FIS) and was given the Alice Springs weather, including the local QNH. At 1945, he advised Adelaide FIS that the aircraft was leaving Flight Level 330 on descent. At about 30 miles from Alice Springs, the pilot in command turned the aircraft right to track for the offset RNAV position 292 degrees/11 miles Alice Springs. The crew set local QNH passing 16,000 feet and then completed the remaining transition altitude checks. These included selecting landing and taxi lights on. At 1949, the co-pilot advised Adelaide FIS that the aircraft was transferring frequency to the Alice Springs MTAF. At 1953, the aircraft passed Simpson’s Gap at about 4,300 feet and the copilot set 3,500 feet in the altitude alert selector. About 15 seconds later, the pilot in command told the co-pilot that, after the aircraft passed overhead the next locator, he was to set the ‘minima’ in the altitude alert selector. At 1954 , the pilot in command called that the aircraft was at 3,500 feet. A few seconds later, the co-pilot indicated that the aircraft was over the Temple Bar locator and that they could descend to 2,300 feet. The pilot in command repeated the 2,300 feet called by the co-pilot and asked him to select the landing gear down. The crew then completed the pre-landing checks. Eleven seconds later, the co-pilot reported that the aircraft was 300 feet above the minimum descent altitude. This was confirmed by the pilot in command. About 10 seconds later, there were two calls by the co-pilot to pull up. Immediately after the second call, the aircraft struck the top of the Ilparpa Range (approximately 9 kilometres north-west of Alice Springs Airport), while heading about 105 degrees at an altitude of about 2,250 feet in a very shallow climb. At approximately 1950, witnesses in a housing estate on the north-western side of the Ilparpa Range observed aircraft lights approaching from the north-west. They described the lights as appearing significantly lower than those of other aircraft they had observed approaching Alice Springs from the same direction. The lights illuminated buildings as the aircraft passed overhead and then they illuminated the northern escarpment of the range. This was followed almost immediately by fire/explosion at the top of the range.
Probable cause:
The following factors were considered significant in the accident sequence:
1. There were difficulties in the cockpit relationship between the pilot in command and the co-pilot.
2. The level of crew resource management demonstrated by both crew members during the flight was low.
3. The Alice Springs locator/NDB approach was unique.
4. The briefing for the approach conducted by the pilot in command was not adequate.
5. When asked for the ‘minima’ by the pilot in command, the co-pilot called, and the pilot in command accepted, an incorrect minimum altitude for the aircraft category and for the segment of the approach.
6. The technique employed by the pilot in command in flying the approach involved a high cockpit workload.
7. The crew did not use the radio altimeter during the approach.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Yea

Date & Time: Mar 16, 1995 at 1400 LT
Type of aircraft:
Operator:
Registration:
VH-IDB
Flight Phase:
Survivors:
Yes
Schedule:
Yea - Yea
MSN:
883
YOM:
1956
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1468
Captain / Total hours on type:
244.00
Circumstances:
The pilot reported that the flight departed from an agricultural strip located in a valley surrounded by hills. The aircraft carried a full load of superphosphate to be spread on a property approximately one mile from the strip. The pilot had previously surveyed the property and the flight path. He had selected a route that took him up through a valley between hills and then over a low ridge to the property. After take off the pilot set climb power and selected climb flap in order to follow his predetermined route to the property. The pilot advised that as the aircraft flew towards the low ridge it appeared to be descending rather than climbing. He elected to carryout a partial dump and to apply extra flap to clear a clump of trees. The speed deteriorated to 60 knots from the initial climb speed of 70 knots. The pilot did not increase power. Some 300 metres later another partial dump was carried out to clear another tree. As that tree was cleared the pilot again initiated a partial dump and turned to the right in an endeavour to escape from a rapidly deteriorating situation. Immediately the turn was initiated the right wing dropped and the aircraft stalled, impacting the ground onto the right wing and cartwheeled to a stop some 50 metres from the initial impact. The company chief pilot examined the accident site and advised that the flight path through the valley was in a classic false horizon situation whereby the surrounding hills caused the pilot to consider that the flight path was over flat terrain whilst in reality the terrain was rising approximately 5 degrees up to the ridge. The chief pilot also advised that the aircraft would not have been able to outclimb the terrain at high gross weight with only cruise power set.
Probable cause:
Examination of the wreckage did not disclose any pre-impact factors that may have contributed to the accident. Weather and pilot workload were not considered to be factors in this accident.
The pilot had flown approximately 1200 hours on agricultural operations and 244 hours on the type. His loss of situational awareness could be due in part to his relatively low experience.
The following factors were considered relevant to the development of the accident:
- At high weight, and with climb power applied, the pilot flew the aircraft on an inappropriate flight path into rising terrain.
- The pilot did not take appropriate remedial actions when the aircraft could not outclimb the terrain and the aircraft speed deteriorated.
- The pilot lost control of the aircraft while attempting a turn at low speed.
Final Report: