Crash of a Piper PA-31-350 Navajo Chieftain in Young: 7 killed

Date & Time: Jun 11, 1993 at 1918 LT
Registration:
VH-NDU
Survivors:
No
Schedule:
Sydney – Cowra – Young – Cootamundra
MSN:
31-8152083
YOM:
1981
Flight number:
OB301
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
1822
Captain / Total hours on type:
337.00
Copilot / Total flying hours:
954
Copilot / Total hours on type:
43
Aircraft flight hours:
3936
Circumstances:
At about 1500 hours EST, 11 June 1993, a standard company flight plan held by the CAA at the Melbourne flight briefing facility was activated. The plan indicated that Piper PA-31-350 aircraft VH-NDU would be conducting flight OB 301, a regular public transport service from Sydney (Kingsford Smith) airport to Cootamundra NSW, with intermediate landings at Cowra and Young. The flight was planned to be operated in accordance with IFR procedures, with a scheduled departure time from Sydney of 1720. The aircraft was to be crewed by two pilots. Prior to departure, the company scheduled a second aircraft to operate the Sydney–Cowra sector. Consequently, VH-NDU was required to land only at Young and Cootamundra. At that time of the year, the 1720 departure time meant that the flight would be conducted entirely at night. VH-NDU departed Sydney at 1738 carrying five passengers, with a fuel endurance of about 253 minutes. The pilot-in-command occupied the left cockpit seat. The aircraft initially tracked via the direct Sydney to Cowra route and climbed to a cruising altitude of 8,000 feet. At 1801 the pilot reported to Sydney FIS that the aircraft was now tracking direct to Young, and would report at Riley, an en route reporting point located 62 NM from Young on the Katoomba– Young track. FIS advised the area QNH was 1003 hPa. At 1814 the pilot reported the aircraft was at Riley and estimated arrival at Young at 1835. By 1820 the pilot had reported on descent to Young, with in-flight conditions of cloud and heavy rain. Recorded radar data later showed that the aircraft passed 13.5 NM to the south-east of Riley, south of the direct Katoomba–Young track. At about 18.5 NM north-east of Rugby, the aircraft turned right and initially tracked about 280° before turning left to track direct to Young. When queried by FIS at 1836, the pilot amended the estimate for his arrival at Young to 1838. At 1842, after prompting from FIS, the pilot reported at Young that he was commencing an NDB approach, and would call again on the hour or in the circuit. Shortly after 1845 witnesses at Young aerodrome saw the lights of an aircraft, which they believed to be VH-NDU, pass low overhead after approaching from the east. Some minutes later the same aircraft was seen to pass over the aerodrome from the opposite direction and appear to climb away towards the east. On both occasions the runway and aerodrome lights were not illuminated, although the aerodrome was equipped with PAL and it was the responsibility of the pilot-in-command to activate it. At 1850 FIS advised VH-NDU of the proximity of Cessna 310 aircraft, VH-XMA, which was estimating arrival at Young at 1900. VH-XMA subsequently reported holding in visual conditions at about 8 NM north of Young. The pilot of VH-NDU reported at 1903 that he was on another overshoot at Young, about to commence another approach, and would report again at 1915. FIS provided additional traffic on Piper PA31 aircraft, VH-XML, which was also estimating Young at 1915. At about this time witnesses reported seeing the runway lights illuminate. VH-XMA then proceeded to Young and landed on runway 01 at about 1912. At 1916 VH-NDU reported in the Young circuit area and cancelled SARWATCH. A pilot witness said that the aircraft passed over the northern end of the aerodrome from a westerly direction before turning right and taking up a heading consistent with a right downwind leg for a landing on runway 01. The aircraft was then seen to turn right and pass to the south of the aerodrome before entering what appeared to be a right downwind leg for runway 19. When abeam the aerodrome the aircraft again turned right and overflew the aerodrome to enter a second right downwind leg for runway 01. Another witness thought the aircraft (VH-NDU) was significantly lower than another aircraft approaching from the east (VH-XML). Shortly after VH-NDU turned onto an apparent base leg the navigation lights were lost to sight. Almost immediately a fireball was observed, consistent with the final position of the aircraft (see figure 2). At 1918 the pilot of VH-XMA telephoned the 000 emergency services number and reported the accident to the Goulburn Ambulance Control Centre. By 1920 this information had been relayed to the Young Ambulance Service, the Young Police, and the Young SES. An off-duty Fire Brigade officer, who was waiting at the aerodrome, drove into Young and alerted the Fire Brigade at 1930. The emergency services initially travelled to Young Aerodrome but were unable to gain immediate access to the accident site, which was located on a hill some 2.2 km to the south-south-east of the aerodrome, in an area remote from roads and lighting. Access was finally gained from a road located south of the accident site. An ambulance reached the aircraft wreckage at 1952 and the crew were able to rescue and resuscitate the only survivor, who was critically injured, and transport her to the Young Hospital. She died at Camperdown Children’s Hospital at 0510 the next morning.
Probable cause:
Significant factors
1. The cloudbase in the Young circling area was below the minimum circling altitude, associated with dark night conditions and limited ground lighting.
2. The workload of the pilot-in-command was substantially increased by the effects of aircraft equipment deficiencies, with a possible consequent degrading of his performance as a result of skill fatigue.
3. The instrument approach and landing charts did not provide the flight crew with terrain information adequate for the assessment of obstacle clearance during a circling approach.
4. The Monarch operations manual did not provide the flight crew with guidance or procedures for the safe avoidance of terrain at Young during a night-circling approach.
5. The aircraft descended below the minimum circling altitude without adequate monitoring of obstacle clearance by the crew.
6. The visual cues available to the flight crew were insufficient as a sole source of height judgement.
7. There were organisational deficiencies in the management and operation of RPT services by Monarch.
8. There were organisational deficiencies in the safety regulation of Monarch RPT operations by the CAA.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Innemincka

Date & Time: May 29, 1993 at 1258 LT
Registration:
VH-LIC
Flight Phase:
Survivors:
Yes
Schedule:
Port Augusta – Innamincka – Durham Downs
MSN:
31-7652173
YOM:
1976
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2930
Captain / Total hours on type:
966.00
Circumstances:
The pilot was conducting a scheduled passenger service flight from Port Augusta with a stop at Innamincka. A commercial pilot, travelling as a non-paying passenger, occupied the co-pilot's seat to observe the operation. Two additional passengers were on board the aircraft for the entire flight. After landing at Innamincka, the aircraft was refuelled by the pilot in command and the oil levels of both engines were checked by the observer, who experienced difficulty securing the combination oil filler cap-dipsticks. He asked the pilot for instructions and, although some advice was given, the pilot did not check the security of the dipsticks. Take-off was commenced towards the north into a 10-15 knot wind with a surface temperature of about 20 degrees C. Shortly after lift-off, at the first power reduction, the observer in the co-pilot's seat advised that there was oil seeping back along the cowl from the right side oil filler hatch. The pilot reported that he increased power to both engines but believed there was no response from the right. He began an immediate left turn to complete a circuit and attempted to secure the right engine and feather the propeller. The aircraft then began a roll to the right, the nose dropped and the aircraft impacted the ground. As the aircraft rolled right and the nose dropped, the pilot reported that he had secured the left engine and feathered the propeller. The observer in the co-pilot seat reported hearing a continuous stall warning horn as the right wing began to drop. All occupants, although injured, were able to vacate the aircraft through the main cabin door. The pilot provided assistance to the passengers and then returned to the airport to summon help.
Probable cause:
Examination of the wreckage revealed that the aircraft impacted the ground in a nose down, right wing low attitude while turning right. The landing gear collapsed due to impact forces and the right wing separated. Deceleration and impact forces were severe. The right propeller was found in the fine pitch range with no damage to the uppermost blade and the other two bent backwards. The right engine oil filler cap-dipstick was found to be correctly installed in the oil filler neck. There was a pattern of engine oil over the rear of the engine and inside the cowl originating from the oil filler neck. The left engine was partially torn from its mountings and displaced about 90 degrees to the right. Its propeller was in the fully feathered position. The oil filler cap-dipstick was on the ground adjacent to the engine. An oil spill pattern similar to that on the right engine was evident.
Significant Factors:
- The pilot-in-command reacted inappropriately to a perceived engine problem shortly after take-off.
- Control of the aircraft was lost at a height insufficient to effect a recovery.
Final Report:

Crash of a Swearingen SA226AC Metro II in Mackay

Date & Time: Apr 14, 1993 at 0525 LT
Type of aircraft:
Operator:
Registration:
VH-UZS
Flight Type:
Survivors:
Yes
Schedule:
Brisbane - Mackay
MSN:
TC-320
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2670
Captain / Total hours on type:
181.00
Circumstances:
The aircraft was operating a freight charter flight, cruising normally at an altitude of 20,000 ft (FL200), when, about 150 km south-east of Mackay, the left engine lost power and could not be restarted. During the subsequent landing on runway 14 at Mackay, the pilot attempted a single engine go-around when he suddenly had the (mistaken) impression that the landing gear was not down. He temporarily lost control of the aircraft but recovered to touch down on the flight strip to the left of the runway, some 500 m before the runway end. During the landing roll, the landing gear collapsed and the aircraft sustained substantial damage.
Probable cause:
The report concludes that the engine power loss was caused by failure of the fuel pump high pressure relief valve. The pilot, believing that the landing gear was still retracted, initiated action to avoid a wheels-up landing. This action was initiated too late in the landing approach for a successful outcome.
Final Report:

Crash of a Fletcher FU24-954 in Coogah: 1 killed

Date & Time: Mar 16, 1992
Type of aircraft:
Operator:
Registration:
VH-EOG
Flight Phase:
Survivors:
No
Site:
MSN:
3
YOM:
1954
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Crashed in unknown circumstances in a hilly terrain while engaged in a superphosphate spraying mission. The pilot, sole on board, was killed.

Crash of a Pilatus PC-6/B1-H2 Turbo Porter in Jaspers Brush: 2 killed

Date & Time: Nov 12, 1991
Operator:
Registration:
A14-683
Flight Phase:
Survivors:
Yes
Schedule:
Jaspers Brush - Jaspers Brush
MSN:
683
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
7415
Circumstances:
Crashed in unknown circumstances after takeoff from Jaspers Brush Airfield. Two occupants were killed and eight others were injured.

Crash of a Boeing 707-368C off Woodside Beach: 5 killed

Date & Time: Oct 29, 1991 at 1147 LT
Type of aircraft:
Operator:
Registration:
A20-103
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Richmond - §Avalon
MSN:
21103
YOM:
1975
Flight number:
Windsor 380
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The aircraft departed Richmond on a flight to Avalon, carrying five crew members. While cruising at an altitude of 5,000 feet along the coast, the aircraft lost height and plunged in the sea. The wreckage was found about one km off Woodside Beach and all five occupants were killed. At the time of the accident, weather conditions were good.
Crew:
Cpt Mark Lewin, pilot,
F/Lt Tim Ellis, copilot,
F/Lt Mark Duncan, pilot,
W/O Jon Fawcett, flight engineer,
W/O Al Gwynne, loadmaster.
Probable cause:
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.

Crash of a GAF Nomad N.22B near Tenterfield: 4 killed

Date & Time: Sep 9, 1991
Type of aircraft:
Operator:
Registration:
A18-303
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Oakey - Melbourne
MSN:
003
YOM:
1975
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The crew was completing a training mission consisting of touch-and-go at Ag Strip located 20 km east of Tenterfield. After takeoff, while in initial climb, the twin engine aircraft struck a tree, stalled and crashed, bursting into flames. All four crew members were killed.
Crew:
Maj Lynn Hummerston,
Cpl Peter McCarthy +2 PNGDF pilots.
Probable cause:
As the aircraft was totally destroyed and due to lack of evidences, the exact cause of the accident could not be determined.

Crash of a Lockheed P-3C Orion off Cocos Islands: 1 killed

Date & Time: Apr 26, 1991
Type of aircraft:
Operator:
Registration:
A9-754
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
185-5662
YOM:
1978
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft was engaged in a local flight and was carrying 17 passengers and a crew of four. After takeoff from Cocos Island Airport, the crew climbed to 5,000 feet then reduced his altitude for a low pass over the airport. Approaching the airport at a speed of 380 knots and at a height of about 300 feet, the pilot-in-command increased engine power in a way to gain height when the aircraft lost several pieces from the left wing. Due to severe vibrations and problems of controllability, the crew decided to attempt an emergency landing near the airport. The aircraft struck the ground, lost its undercarriage and came to rest in shallow water. A passenger was killed after being hit by propeller blades that punctured the fuselage. All 20 other occupants escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
Forced landing following severe vibrations after several elements from the left leading edge detached in flight.

Crash of a Rockwell Turbo Commander 681 in Tamworth: 1 killed

Date & Time: Feb 14, 1991 at 1025 LT
Operator:
Registration:
VH-NYG
Flight Type:
Survivors:
No
Schedule:
Brisbane - Moree - Tamworth
MSN:
681-6004
YOM:
1969
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3022
Captain / Total hours on type:
37.00
Aircraft flight hours:
3717
Circumstances:
VH-NYG had departed Tamworth three days before the accident on an extended passenger charter through Sydney, Moree, Emerald, Brisbane, Moree, and Tamworth. On the day of the accident, the pilot had submitted a flight plan nominating a charter category, single pilot, Instrument Flight Rules flight from Brisbane to Moree, then Tamworth. The flight plan indicated that the aircraft carried 1400 Ib (635 kg) of fuel and had an endurance of 211 min. The aircraft, with four passengers on board, departed Brisbane at 0902 hours and landed at Moree at 1010 after an uneventful flight. All four passengers left the flight at Moree. The pilot reported taxiing at Moree to Dubbo Flight Service at 1047 and called airborne at 1050. At 1117 hours the aircraft was given a clearance to enter the Tamworth Control Zone on descent from 10000 ft. The pilot was told to expect a right downwind leg for runway 30. At 1125 the pilot requested a change of runway to runway 18, stating that there was a fuel flow problem with the left engine. The aerodrome controller (ADC) issued a change of runway (runway 18) to the aircraft, asking the pilot whether emergency conditions existed. The pilot answered in the negative and about 30 sec later informed the ADC that he was conducting one left orbit. The orbit was commenced at about 300 ft above ground level (agl) and approximately above the threshold of runway 18. The orbit was flown with an angle of bank of about 60°. The aircraft developed a high rate of descent during the orbit and rolled wings level in a pronounced nose-down attitude after turning through almost 360°. The aircraft then struck the ground in a grassed paddock about 350 m short of the threshold of runway 18 and in line with the right edge of the flight strip. The aircraft, largely intact, slid in the direction of the runway for 53 m before coming to rest. The pilot, sole on board, was killed.
Probable cause:
The following findings were reported:
- The pilot was misled by erroneous fuel consumption data from the aircraft trend monitoring sheet, the endorsing pilot, and the company fuel planning figures.
- The pilot did not ensure that sufficient fuel was carried in the aircraft to complete the planned flight.
- The pilot made an improper in-flight decision to change runways during a forced landing attempt.
- The pilot misjudged the forced landing approach.
- The pilot was unable to recover the aircraft from the high rate of descent which developed during the approach.
Final Report:

Crash of a Cessna 207A Stationair 7 near Jabiru

Date & Time: Jan 7, 1991 at 1523 LT
Operator:
Registration:
VH-MNN
Flight Phase:
Survivors:
Yes
Schedule:
Jabiru - Jabiru
MSN:
207-0439
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was nearing the completion of a scenic flight, maintaining about 800 feet above ground level, when the engine power reduced to 20 inches hg manifold pressure. The engine continued to run smoothly but failed to respond when the pilot advanced the throttle. All other means attempted by the pilot to restore the lost power were unsuccessful. The aircraft, which had a full compliment of persons on board, was too heavy to maintain height under these conditions. As it was flying over forest the pilot turned the aircraft towards the south-west where a more favourable open area, with a road and an airstrip, was available. This entailed having to cross an escarpment, but due to the aircraft's rate of descent insufficient height remained, committing the pilot to a forced landing in an unsuitable area. The pilot transmitted a distress call, gave the passengers a thorough briefing and prepared the aircraft for the forced landing. The aircraft was slowed down and allowed to sink slowly into the forest, contacting the first tree about seven metres above ground level. It then continued through the trees for 40 metres before coming to rest inverted on the forest floor. All passengers evacuated from the aircraft and were rescued by a helicopter which had responded to the distress call.
Probable cause:
Inspection of the engine determined that it was capable of developing full power at the time of the accident. The throttle cable was found to have separated from the cast bronze throttle control lever at the fuel/air metering unit on the intake manifold. The serrated steel bush in the throttle control lever at the cable attachment had become loose, causing the hole to wear elongated which reduced the edge distance from the hole to the end of the control lever sufficiently for it to fail when the throttle was opened. This probably occurred during the last takeoff. During flight, the bush, which was still attached to the cable ball end by the bolt, was probably in such a position as to operate the lever when the throttle control was moved to reduce power for climb and cruise. As the flight progressed and the cable separated from the lever, in-flight movement and vibration would have moved the throttle towards the closed position, with the subsequent reduction in power. Further inspection found that the assembly of the cable to the lever was incorrect, with the washer from under the bolt head being omitted. This reduced the bearing area at the bolt head to the control lever, with the possibility that the bolt may have only been clamped to the bush assisting any movement of the bush in the lever. Once the steel bush started moving in the softer bronze material the rate of wear would have been rapid. The aircraft had flown 85 hours since the last periodic inspection, at which time it may have been possible to detect the first signs of wear between the bush and the control lever if information advising of this type of fault had been available.
The following factors were considered relevant to the development of the accident:
- Incorrect assembly of the washers on the control cable attachment bolt may have allowed the bush to start moving in the lever.
- The bush became loose in the control lever, with the subsequent wear elongating the hole allowing the control lever end to fail.
- The throttle control cable separated from the throttle control lever.
- The throttle closed sufficiently during flight to reduce engine power.
- The aircraft was too heavy to maintain flight.
- The aircraft was operating over an area unsuitable for a forced landing.
- Wear between the bush and the lever may have been detectable during the previous periodic inspection if advisory information had been available.
Final Report: