Newcastle Aviation | Bureau of Aircraft Accidents Archives

The aircraft departed Sydney for Melbourne International airport at 0130 on 21 December 1994. En-route cruise was conducted at flight level 140. Melbourne Automatic Terminal Information Service (ATIS) indicated a cloud base of 200 feet for the aircraft's arrival and runway 27 with ILS approaches, was in use. Air Traffic Control advised the pilot of VH-UZB, another company MU2 that was also en-route from Sydney to Melbourne, and the pilot of VH-IAM while approaching the Melbourne area, that the cloud base was at the ILS minimum and that the previous two aircraft landed off their approaches. VH-UZB was slightly ahead of VH-IAM and made a 27 ILS approach and landed. In response to an inquiry from the Tower controller the pilot of VH-UZB then advised that the visibility below the cloud base was 'not too bad'. This information was relayed by the Tower controller to the pilot of VH-IAM, who was also making a 27 ILS approach about five minutes after VH-UZB. The pilot acknowledged receipt of the information and was given a landing clearance at 0322. At 0324 the Approach controller contacted the Tower controller, who had been communicating with the aircraft on a different frequency, and advised that the aircraft had faded from his radar screen. Transmissions to VH-IAM remained unanswered and search-and-rescue procedures commenced. Nothing could be seen of the aircraft from the tower. A ground search was commenced but was hampered by the darkness and reduced visibility. The terrain to the east of runway 27 threshold, in Gellibrand Hill Park, was rough, undulating and timbered. At 0407 the wreckage was found by a police officer. Due to the darkness and poor visibility the policeman could not accurately establish his position. It took approximately another 15-20 minutes before a fire vehicle could reach the scene of the burning aircraft. The fire was then extinguished.

Probable cause:

The following factors were reported:
1. The company's training system did not detect deficiencies in the pilot's instrument flying skills.
2. The cloud base was low at the time of the accident and dark night conditions prevailed.
3. The pilot persisted with an unstabilised approach.
4. The pilot descended, probably inadvertently, below the approach minimum altitude.
5. The pilot may have been suffering from fatigue.

Final Report:

Crash of a Rockwell Grand Commander 690 off Sydney: 1 killed

Date & Time: Jan 14, 1994 at 0114 LT

Type of aircraft:

Rockwell Grand Commander 690

Operator:

Newcastle Aviation

Registration:

VH-BSS

Flight Phase:

Landing (descent or approach)

Flight Type:

Cargo

Survivors:

Site:

Lake, Sea, Ocean, River

Schedule:

Canberra - Sydney

MSN:

690-11044

YOM:

1972

Location:

Sydney-Kingsford Smith

New South Wales

Country:

Australia

Region:

Oceania

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

1800

Captain / Total hours on type:

50.00

Aircraft flight hours:

7975

Circumstances:

On 14 January 1994 at 0114, Aero Commander 690 aircraft VH-BSS struck the sea while being radar vectored to intercept the Instrument Landing System approach to runway 34 at Sydney (Kingsford-Smith) Airport, NSW. The last recorded position of the aircraft was about 10 miles to the south-east of the airport. At the time of the accident the aircraft was being operated as a cargo charter flight from Canberra to Sydney in accordance with the Instrument Flight Rules. The body of the pilot who was the sole occupant of the aircraft was never recovered. Although wreckage identified as part of the aircraft was located on the seabed shortly after the accident, salvage action was not initially undertaken. This decision was taken after consideration of the known circumstances of the occurrence and of the costs of salvage versus the potential safety benefit that might be gained from examination of the wreckage. About 18 months after the accident, the wing and tail sections of the aircraft were recovered from the sea by fishermen. As a result, a detailed examination of that wreckage was carried out to assess the validity of the Bureau’s original analysis that the airworthiness of the aircraft was unlikely to have been a factor in this accident. No evidence was found of any defect which may have affected the normal operation of the aircraft. The aircraft descended below the altitude it had been cleared to by air traffic control. From the evidence available it was determined that the circumstances of this accident were consistent with controlled flight into the sea.

Probable cause:

Findings
1. The pilot held a valid pilot licence, endorsed for Aero Commander 690 aircraft.
2. The pilot held a valid multi-engine command instrument rating.
3. There was no evidence found to indicate that the performance of the pilot was adversely affected by any physiological or psychological condition.
4. The aircraft was airworthy for the intended flight, despite the existence of minor anomalies in maintenance and serviceability of aircraft systems.
5. The aircraft carried fuel sufficient for the flight.
6. The weight and balance of the aircraft were estimated to have been within the normal limits.
7. Recorded radio communications relevant to the operation of the aircraft were normal.
8. Relevant ground-based aids to navigation were serviceable.
9. At the time of impact the aircraft was capable of normal flight.
10. The aircraft was fitted with an altitude alerting system.
11. The aircraft was not fitted with a ground proximity warning system.
12. The aircraft was equipped with a transponder which provided aircraft altitude information to be displayed on Air Traffic Control radar equipment.
3.2 Significant factors
1. The pilot was relatively inexperienced in single-pilot Instrument Flight Rules operations on the type of aircraft being flown.
2. The aircraft was being descended over the sea in dark-night conditions.
3. The workload of the pilot was significantly increased by his adoption of a steep descent profile at high speed, during a phase of flight which required multiple tasks to be completed in a limited time prior to landing. Radio communications with another company aircraft during that critical phase of flight added to that workload.
4. The pilot probably lost awareness of the vertical position of the aircraft as a result of distraction by other tasks.
5. The aircraft was inadvertently descended below the altitude authorized by Air Traffic Control.
6. The secondary surveillance radar system in operation at the time provided an aircraft altitude readout which was only updated on every sixth sweep of the radar display.
7. The approach controller did not notice a gross change of aircraft altitude shortly after a normal radio communication with the pilot.

Final Report: