Crash of a Britten-Norman BN-2A Islander in Port Vila: 1 killed

Date & Time: Jul 15, 2024 at 1553 LT
Type of aircraft:
Operator:
Registration:
YJ-AT2
Survivors:
Yes
Schedule:
Aneityum – Port Vila
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Following a flight from Aneityum Island, the pilot was approaching Port Vila Airport when the twin engine airplane crashed in a wooded area located southeast of the airport of Port Vila-Bauerfield. The airplane was destroyed and all five occupants were transported to a local hospital. About two days after the accident, one of the survivors died from injuries sustained.

Crash of a Beechcraft 65-B80 Queen Air in Woleai

Date & Time: Jul 12, 2024 at 1110 LT
Type of aircraft:
Operator:
Registration:
N44MA
Flight Phase:
Survivors:
Yes
Schedule:
Woleai – Colonia
MSN:
LD-412
YOM:
1969
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While taking off from Woleai Island Airport in rain, the twin engine airplane veered off runway, lost its undercarriage and came to a halt nearby a wooded area. All nine occupants escaped unhurt. It is believed that the airplane was en route to Colonia on a taxi flight.

Crash of a Cessna 208B Grand Caravan on Lizard Island

Date & Time: Jan 8, 2024 at 0700 LT
Type of aircraft:
Registration:
VH-NWJ
Survivors:
Yes
Schedule:
Lizard Island - Cairns
MSN:
208B-2161
YOM:
2010
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After takeoff from Lizard Island Airport, the crew continued to climb until he reached the altitude of 4,000 feet. Due to an engine malfunction, the crew decided to return to Lizard Island Airport but the airplane overshot and crashed, coming to rest upside down. All 10 occupants were injured and evacuated.

Crash of a Cessna 421C Golden Eagle III off Sunshine Coast

Date & Time: Nov 10, 2023 at 0906 LT
Operator:
Registration:
VH-VPY
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Sunshine Coast - Pago Pago
MSN:
421C-0688
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed Sunshine Coast-Caloundra Airport at 0733LT on a flight to Pago Pago, US Samoa, with two people on board. About 45 minutes into the flight, while cruising at an approximate altitude of 12,000 feet, the pilot inform ATC about an engine failure and elected to return to Sunshine Coast. He made a 180 turn and reduced his altitude. About 45 minutes later, unable to reach his departure airport, the pilot ditched the airplane some 30 nautical miles east of Sunshine Coast. Both occupants found refuge in a dinghy and were quickly rescued. The airplane sank and was lost.

Crash of a Rockwell Gulfstream 695A Jetprop 1000 near Cloncurry: 3 killed

Date & Time: Nov 4, 2023 at 1430 LT
Operator:
Registration:
VH-HPY
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Toowoomba - Mount Isa
MSN:
96051
YOM:
1982
Flight number:
BDOG370
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
In the early afternoon, the twin engine airplane departed Toowoomba Airport on an aerial survey flight under callsign BDOG370 to Mount Isa with three people on board. The purpose of the flight was to conduct a survey mission of the area in case of bushfire. While cruising at an altitude of 28,000 feet, the airplane entered an uncontrolled descent. It reached a rate of descent of 9,600 feet per minute until it crashed in an uninhabited area located approximately 70 km southeast of Cloncurry. All three occupants were killed.

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

Date & Time: Apr 7, 2023 at 0605 LT
Operator:
Registration:
VH-HJE
Flight Type:
Survivors:
Yes
Schedule:
Bankstown – Brisbane
MSN:
31-7852074
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1473
Captain / Total hours on type:
204.00
Circumstances:
On 7 April 2023, the pilot of a Piper Aircraft Corporation PA-31-350 Chieftain (PA-31), registered VH-HJE and operated by Air Link, was conducting a freight charter flight from Archerfield, Queensland. The planned flight included one intermediate stop at Bankstown, New South Wales before returning to Archerfield, and was conducted under the instrument flight rules at night. The aircraft departed Archerfield at about 0024 local time and during the first leg to Bankstown, the pilot reported an intermittent fault with the autopilot, producing uncommanded pitch changes and associated rates of climb and descent of around 1,000 ft/min. As a result, much of the first leg was flown by hand. After landing at Bankstown at about 0248, a defect entry was made on the maintenance release; however, the pilot was confident that they would be able to hand fly the aircraft for the return leg and elected to continue with the planned flight. The aircraft was refueled to its maximum capacity for the return leg after which a small quantity of water was detected in the samples taken from both main fuel tanks. Additional fuel drains were conducted until the fuel sample was free of water. The manifested freight for the return leg was considered a light load and the aircraft was within weight and balance limitations. After taking off at 0351, the pilot climbed to the flight planned altitude of 9,000 ft. Once established in cruise, the pilot changed the left and right fuel selectors from the respective main tank to the auxiliary tank. The pilot advised that, during cruise, they engaged the autopilot and the uncommanded pitch events continued. Consequently, the pilot did not use the autopilot for part of the flight. Approaching top of descent, the pilot recalled conducting their normal flow checks by memory before referring to the checklist. During this time, the pilot completed a number of other tasks not related to the fuel system, such as changing the radio frequency, checking the weather at the destination and briefing themselves on the expected arrival into Archerfield. Shortly after, the pilot remembered changing from the auxiliary fuel tanks back to the main fuel tanks and using the fuel quantity gauges to confirm tank selection. The pilot calculated that 11 minutes of fuel remained in the auxiliary tanks (with an estimated 177 L in each main tank). Around eight minutes after commencing descent and 28 NM (52 km) south of Archerfield (at 0552), the pilot observed the right ‘low fuel flow’ warning light (or ‘low fuel pressure’) illuminate on the annunciator panel. This was followed soon after by a slight reduction in noise from the right engine. As the aircraft descended through approximately 4,700 ft, the ADS-B data showed a moderate deceleration with a gradual deviation right of track. While the power loss produced a minor yaw to the right, the pilot recalled that only a small amount of rudder input was required to counter the adverse yaw once the autopilot was disconnected. Without any sign of rough running or engine surging, they advised that had they not seen the annunciator light, they would not have thought there was a problem. Over the next few minutes, the pilot attempted to troubleshoot and diagnose the problem with the right engine. Immediately following power loss, the pilot reported they:
• switched on both emergency fuel boost pumps
• advanced both mixture levers to RICH
• cycled the throttle to full throttle and then returned it to its previous setting without fully closing the throttle
• moved the right fuel selector from main tank to auxiliary
• disconnected the autopilot and retrimmed the aircraft. This did not alter the abnormal operation of the right engine, and the pilot conducted the engine roughness checklist from the aircraft pilot’s operating handbook noting the following:
• oil temperature, oil pressure, and cylinder head temperature indicated normally
• manifold absolute pressure (MAP) had decreased from 31 in Hg to 27 inHg
• exhaust gas temperature (EGT) indicated in the green range
• fuel flow indicated zero.
With no indication of mechanical failure, the pilot advised they could not rule out the possibility of fuel contamination and chose not to reselect the main tank for the remainder of the flight. After considering the aircraft’s performance, handling characteristics and engine instrument indications, the pilot assessed that the right engine, while not able to generate normal power, was still producing some power and that this would assist in reaching Archerfield. Based on the partial power loss diagnosis, the pilot decided not to shut down and secure the engine which would have included feathering the propeller. At 0556, at about 20 NM south of Archerfield at approximately 3,300 ft, the pilot advised air traffic control (ATC) that they had experienced an engine malfunction and requested to maintain altitude. With maximum power being set on the fully operating left engine, the aircraft was unable to maintain height and was descending at about 100 ft/min. Even though the aircraft was unable to maintain height, the pilot calculated that the aircraft should have been able to make it to Archerfield and did not declare an emergency at that time. At 0602, about 12 minutes after the power loss on the right engine, the left engine began to run rough and the pilot observed the left low fuel flow warning light illuminate on the annunciator panel. This was followed by severe rough running and surging from the left engine which produced a series of pronounced yawing movements. The pilot did not run through the checklist a second time for the left engine, reporting that they completed the remaining item on the checklist for the left engine by switching the left engine’s fuel supply to the auxiliary tank. The pilot once again elected not to change tank selections back to mains. With both engines malfunctioning and both propellers unfeathered, the rate of descent increased to about 1,500 ft/min. The pilot advised that following the second power loss, it was clear that the aircraft would not be able to make it to Archerfield and their attention shifted from troubleshooting and performance management to finding somewhere to conduct a forced landing. ADS-B data showed the aircraft was at about 1,600 ft when the left engine malfunctioned. The pilot stated that they aimed to stay above the minimum control speed, which for VH-HJE was 72 kt. The aircraft was manoeuvred during the brief search), during which time the ground speed fluctuated from 110 kt to a low of 75 kt. It was calculated that in the prevailing wind, this would have provided an approximate indicated airspeed of 71 kt; equal to the aircraft’s clean configuration stall speed. The pilot declared an emergency and advised ATC that they were unable to make Archerfield Airport and would be conducting an off-airport forced landing. With very limited suitable landing areas available, the pilot elected to leave the flaps and gear retracted to minimize drag to ensure they would be able to make the selected landing area. At about 0605, the aircraft touched down in a rail corridor beside the railway line, and the aircraft’s left wing struck a wire fence. The aircraft hit several trees, sustaining substantial damage to the fuselage and wings. The pilot received only minor injuries in the accident and was able to exit through the rear door of the aircraft.
Probable cause:
The following contributing factors were identified:
- It is likely that the pilot did not action the checklist items relating to the selection of main fuel tanks for descent. The fuel supply in the auxiliary tanks was subsequently consumed resulting in fuel starvation and loss of power from the right then left engine.
- Following the loss of power to the right engine, the pilot misinterpreted the engine instrument indications as a partial power loss and carried out the rough running checklist but did not select the main tanks that contained substantial fuel to restore engine power, or feather the propeller. This reduced the available performance resulting in the aircraft being unable to maintain altitude.
- When the left engine started to surge and run rough, the pilot did not switch to the main tank that contained substantial fuel, necessitating an off‑airport forced landing.
- It is likely that the pilot was experiencing a level of fatigue shown to have an effect on performance.
- As the pilot was maneuvering for the forced landing there was a significant reduction of airspeed. This reduced the margin over the stall speed and increased the risk of loss of control.
- Operator guidance material provided different fuel flow figures in the fuel policy and flight crew operating manual for the PA-31 aircraft type.
- The operator’s fuel monitoring practices did not detect higher fuel burns than what was specified in fuel planning data.
- The forced landing site selected minimized the risk of damage and injury to those on the ground and the controlled touchdown maximized the chances of survivability.
Final Report:

Crash of a Pacific Aerospace PAC 750XL in Kudjip

Date & Time: Feb 9, 2023 at 1250 LT
Operator:
Registration:
P2-BJD
Flight Phase:
Survivors:
Yes
Schedule:
Giramben - Simbai
MSN:
124
YOM:
2005
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3582
Captain / Total hours on type:
1885.00
Aircraft flight hours:
13811
Aircraft flight cycles:
17220
Circumstances:
The flight was planned to depart Giramben at 12:40, and track North for Simbai Airstrip, Madang Province at 9,000 ft AMSL. According to the pilot, the aircraft was loaded by NCA ground handlers following his instructions. The manifest was completed by one of the ground handler, who stated that the aircraft was loaded by the other ground handlers while he was completing the manifest in the vehicle, due to no proper shed for him to work from. The pilot also stated that at the time the loading was completed, and the passengers had boarded the aircraft, he observed that the winds were variable, blowing directly from the North and from the East as well. Recorded data showed that the aircraft commenced taxiing at 12:44. During the take-off roll, at the expected airborne point, about 500 m down the runway, as the aircraft accelerated with the airspeed approaching 60 knots, the right wheel hit a soft spot on the strip which dramatically reduced the momentum and speed of the aircraft, as described by the pilot. Eyewitnesses reported seeing the aircraft getting airborne briefly and got back on the ground again. The pilot recalled that by the time the aircraft got back on the ground he realized that he had passed the nominated committal point, which was identified during onsite activities to be about 540 m from the threshold of runway 16. The pilot opted to continue with the take-off roll, with full power hoping that the aircraft would regain speed on the remaining part of the strip to get airborne again. The pilot recalled reaching the end of the runway and getting airborne again with an airspeed of 50 kts airborne again, however, the right wheel got caught on the barbed wire of the perimeter fence that ran across to the runway, and subsequently impacted terrain. The pilot stated that he had lost consciousness at the time of the initial impact and therefore, had no recollection from thereon. The investigation found that the aircraft got airborne about 19 m past the end of runway 16. However, the aircraft’s main landing gears got caught on the perimeter fencing wire, subsequently impacting ground about 100 m from the end of the runway, then continued with the momentum and came to rest, in a local village garden about 160 m from the end of the runway. The aircraft was destroyed by impact forces. The pilot and passengers were rescued by the locals and taken to Nazarene General Hospital, Jiwaka Province, for treatment. The pilot, male adult and infant passengers sustained serious injuries, and the female passenger sustained minor injuries.
Probable cause:
The following factors were identified:
- The pilot did not complete a trim sheet for the flight.
- The manifest was completed by a ground handler who was not present at the time the cargo was being loaded by other ground handlers. The manifest was not signed by the ground handler who completed it, nor was it authorized by the pilot before departure.
- Pilot’s lack of supervision of the aircraft’s loading process to ensure cargo is loaded correctly and in accordance with the prescribed limitations and to prevent calculation errors. As a result, it was likely that the aircraft was overweight when it departed.
- Wet strip surface conditions that caused significant resistance during the take-off roll and impeded the aircraft’s ability to reach its required lift off airspeed.
- Pilot’s decision to continue the take-off roll after passing the committal.
- Training deficiencies of ground handlers and the pilot.
- The lack of adequate Quality Assurance systems oversight on the operator’s operating standard procedures.
Final Report:

Crash of a Boeing 737-3H4 in the Fitzgerald River National Park

Date & Time: Feb 6, 2023 at 1614 LT
Type of aircraft:
Operator:
Registration:
N619SW
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Busselton - Busselton
MSN:
28035/2762
YOM:
1995
Flight number:
Bomber 139
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8233
Captain / Total hours on type:
1399.00
Copilot / Total flying hours:
5852
Copilot / Total hours on type:
128
Aircraft flight hours:
69187
Circumstances:
The air tanker, callsign Bomber 139, departed from Busselton Airport, Western Australia (WA) on a firefighting task to Fitzgerald River National Park, WA. There were 2 pilots on board, the aircraft captain in the left seat as the pilot flying and a copilot in the right seat as the pilot monitoring. At about 1614, during the go-around from a second partial retardant drop, the aircraft impacted a ridgeline at an elevation of about 222 ft and subsequently crashed, bursting into flames. The pilots suffered minor injuries and the aircraft was destroyed by a post crash fire.
Probable cause:
The ATSB found that the accident drop was conducted at a low height and airspeed downhill, which required the use of idle thrust and a high descent rate. The delay in the engines reaching go-around thrust at the end of the drop resulted in the aircraft’s height and airspeed (energy state) decaying as it approached rising terrain, which was not expected or detected by the pilot flying. Consequently, the aircraft’s airspeed and thrust were insufficient to climb above a ridgeline in the exit path, which resulted in a controlled flight into terrain. The operator’s practice of recalculating, and lowering, their target drop speed after a partial load drop also contributed to the low energy state of the aircraft leading up to the collision with terrain.
The ATSB also found that the operator and tasking agency had not published a minimum drop height, which resulted in the copilot, who did not believe there was a minimum drop height, not making any announcements about the low energy state prior to the collision. The ATSB found the operator’s pilot monitoring duties were reactive to the development of a low energy state and did
not include call-outs either before or at the minimum target parameters to reduce the risk of a low energy state developing.
The ATSB benchmarked the WA, New South Wales and National Aerial Firefighting Centre standards against the United States Forest Service and United States National Wildfire Coordinating Group standards and found inconsistencies between the Australian agencies’ standards but not among the United States agencies’ standards. This was likely a result of each Australian state participating in the LAT program independently producing their own standards.
Final Report:

Crash of a Britten-Norman BN-2A-21 Islander on Moa Island

Date & Time: Oct 3, 2022 at 1338 LT
Type of aircraft:
Operator:
Registration:
VH-WQA
Flight Phase:
Survivors:
Yes
Schedule:
Saibai Island - Horn Island
MSN:
494
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2400
Captain / Total hours on type:
250.00
Aircraft flight hours:
14081
Circumstances:
On the afternoon of 3 October 2022, a Pilatus Britten-Norman Islander BN2A-21, registered VHWQA and operated by Torres Strait Air, was conducting a non-scheduled passenger air transport flight from Saibai Island Airport, Queensland (QLD) to Horn Island Airport, QLD. There was 1 pilot and 6 passengers (students) on board. About 19 km NE of Moa Island both engines began to surge. The pilot diverted towards Kubin Airport on Moa Island. As the aircraft passed to the south of the township of Saint Pauls, the pilot determined there was insufficient altitude remaining to reach the airport. As a result, the pilot conducted a forced landing on a road 7 km ENE of Kubin Airport. There were no reported injuries to the pilot or the passengers. The aircraft was substantially damaged.
Probable cause:
The ATSB found that the dual engine speed fluctuations and associated power loss was probably the result of fuel starvation. The mechanism was not conclusively determined, however it was identified that the pilot did not operate the aircraft's fuel system in accordance with the aircraft flight manual, and that the configuration and location of the aircraft’s fuel controls and tank quantity gauges were probably not conducive to rapid and accurate interpretation. The aircraft manufacturer released a service letter in June 2022 that detailed an optional modification to centralize the fuel system controls and gauges, however this modification was not fitted to VH-WQA. The ATSB considered that these factors increased the risk of inadvertent fuel tank selection.
Final Report:

Crash of a Pacific Aerospace PAC 750XL in Tekin

Date & Time: Jan 26, 2022 at 0943 LT
Operator:
Registration:
P2-BWC
Survivors:
Yes
Schedule:
Kiunga – Oksapmin
MSN:
136
YOM:
2007
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14129
Captain / Total hours on type:
3625.00
Aircraft flight hours:
6752
Aircraft flight cycles:
13861
Circumstances:
The airplane was on a VFR charter flight from Kiunga Airport, Western Province to Tekin Airstrip, Sandaun Province, Papua New Guinea. During the landing roll aircraft sustained a left main landing gear assembly collapse and subsequent runway excursion. There were seven persons onboard: one pilot and six passengers. At 09:06, P2-BWC departed Kiunga Airport and arrived at Tekin circuit area at 09:40. The pilot established the aircraft on the final approach profile, he configured the aircraft for landing by fully extending the flaps and maintained an airspeed of about 80 knots (kts). The pilot also stated that he experienced a downdraft prior to touch down. The aircraft landed at 09:43 with an airspeed of 75 knots as recalled by the pilot. The aircraft touched down about 3m short of the airstrip edge boundary. The investigation determined that due to reduced damping effect of the oleo and/or the tyre of the left main landing gear, the landing gear attachment bolts sustained significant impact stress from the landing impact force and snapped, causing the gear assembly to collapse and separate from the aircraft. Subsequently, the left wing abruptly dropped, and the aircraft began veering to the left, towards the eastern edge of the airstrip. The aircraft continued veering to the left and subsequently the left wingtip struck the outer edge of the extended right-hand flap of P2-BWE, a wreckage of the same aircraft type owned and operated by NASL that was involved in a similar accident on 18 January 2022, causing P2-BWC to abruptly veer further left and skid across the airstrip boundary as the nose-wheel and right main wheel bogged into the ground. The pilot immediately shut down the engine and evacuated the passengers with the assistance of one of the Operator’s personnel who was also a passenger on board. There were no reported injuries and the aircraft sustained significant damage.
Probable cause:
During the landing at Tekin Airstrip, the pilot encountered downdraft and touchdown about 4 metres short of the designated landing threshold. Due to less damping effect on the oleo or the tyre, the landing impact force could have transferred up through the structure and concurrently causing the left main landing gear to collapse. Subsequently, the left wing abruptly dropped and began veering to the left, towards the eastern edge of the airstrip. The aircraft continued veering to the left and subsequently the left wingtip struck the outer edge of the extended right-side flap of P2-BWE, causing it to abruptly veer further left and skid across the airstrip boundary as the nose-wheel and right main wheel bogged into the ground.
Final Report: