Crash of a Cessna 402C in Papa Lealea

Date & Time: Jul 26, 2020 at 1246 LT
Type of aircraft:
Operator:
Registration:
VH-TSI
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Papa Lealea - Mareeba
MSN:
402C-0492
YOM:
1981
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 26 July 2020, at 12:46 local time (02:46 UTC), a Cessna 402C aircraft, registered VH-TSI collided with trees during an aborted take-off at an uncommissioned field near Papa-Lealea, about 16 nm North-West of Port Moresby, Papua New Guinea. The pilot, during interview with the AIC, stated that he departed at 09:30 that day from Mareeba Airport, Queensland Australia and tracked towards the North North-East with a planned track set slightly left of Jacksons International Airport, Port Moresby, National Capital District, Papua New Guinea. As the aircraft neared the Southern shoreline (within the Caution Bay area), he diverted left and began tracking towards the North West along the coast in order to avoid flying over villages in the area. He subsequently crossed over land before turning back to approach the intended landing field. As the aircraft approached to land, the outboard section of the left wing was clipped by a tree and separated from the aircraft. According to the pilot, he continued on with the approach and landed on the field at about 12:20. The pilot reported that he had flown to and within Papua New Guinea in the past and was familiar with the area and airspace. He confirmed that after departing Mareeba, he switched off the transponder. After shutting down the aircraft, the aircraft was refuelled with jerrycans full of fuel (AvGas) and loaded with cargo by persons waiting on the ground. The pilot reported that he estimated that a distance of 800 m would be required for the take-off. According to the pilot, at about 12:40, he lined up and commenced his take-off roll from the Southern end of the field. As the aircraft lifted off, he noticed that the airspeed indicator (ASI) was not working. He also observed that the aircraft was not achieving a positive rate of climb. He subsequently pulled the throttles back and manoeuvred the aircraft back towards the ground. The aircraft touched down with a speed that the pilot described as higher than normal, with about 400 m of usable field remaining. The aircraft continued off the end of the field and into the bushes clipping trees along the way until it came to rest. The pilot informed the AIC that he was the sole occupant of the aircraft, and sustained minor injuries as a result of the occurrence. The aircraft was substantially damaged. The investigation confirmed that the fire to the left wing and engine was a post-accident event and was deliberate. The pilot was later arrested and a load of 500 kilos of cocaine distributed in 28 bales was found at the scene.
Probable cause:
The investigation determined that the separation of the outboard section of the left wing, clipped by a tree during the approach to land phase, affected the ability of the left wing to produce lift. The investigation could not conclusively determine the actual weight and balance of the aircraft as it was not possible to determine the quantity and quality of fuel on board, nor the weight and distribution of the cargo that was on board. The evidence gathered during the investigation did not allow the AIC to discard overweight, balance or centre of gravity issues due to improper loading or restrain of the cargo as factors contributing to the inability of the aircraft to obtain a positive rate of climb during take-off. The evidence of tire marks found by the investigators on the uncommissioned field indicated that the aircraft touched down about 400 m before the end of the field, distance that was not enough for the aircraft to come to a stop, continuing its landing roll into the bushes and impacting trees until it got to its final position. The investigation determined that the aircraft was not airworthy at the time of the accident and was unserviceable for the conduct of the flight. The investigation also determined that there was no proper document control to conduct timely scheduled maintenance and that there was no record of a certificate of airworthiness (CoA) at the time of the accident.
Final Report:

Crash of a PAC Cresco 08-600 near Carterton: 1 killed

Date & Time: Apr 24, 2020 at 0710 LT
Type of aircraft:
Operator:
Registration:
ZK-LTK
Flight Phase:
Survivors:
No
Site:
MSN:
30
YOM:
2002
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
15000
Captain / Total hours on type:
8700.00
Circumstances:
On 24 April 2020 the pilot of a Pacific Aerospace Cresco 08-600 aircraft, registered ZK-LTK (the aeroplane), was conducting agricultural flight operations spreading superphosphate fertilizer on a farm in the Kourarau Hill area, near Masterton. The airstrip was a typical topdressing airstrip, with a downward slope and a left bend of about 5 degrees partway down the strip, in the direction of take-off. The ground at the end of the airstrip dropped sharply away to a valley that ran perpendicular to the direction of the airstrip. On the commencement of the third topdressing flight, witnesses reported, the aeroplane accelerated normally from the loading point. However, the aeroplane did not follow the direction of the airstrip around to the left, as it had done during the previous two flights. Instead, the aeroplane continued in a straight line from the load point and subsequently struck uneven terrain off to the right of the airstrip. The impact with the uneven terrain caused the right main undercarriage assembly to fracture off and damage the right wing and flap. The aeroplane descended into the valley, striking a tree with the right-hand wing, then continued across the valley floor and impacted the far side of the valley, coming to rest inverted. The aeroplane was destroyed by the impacts and a post-crash fire. The sole pilot occupant did not survive the accident sequence.
Probable cause:
The following findings were identified:
- The pilot did not make the necessary left turn during the take-off roll to align with the strip centreline, so the aeroplane continued the take-off roll in a straight line.
- The right-rear undercarriage struck uneven ground with sufficient force to break the undercarriage mounting brackets and dislodge the undercarriage assembly from the aeroplane.
- The right main undercarriage subsequently struck the right flap, resulting in a partial dislocation of the flap. This very likely resulted in the aeroplane becoming uncontrollable.
- The pilot was about as likely as not to have been incapacitated early in the take-off roll.
Final Report:

Crash of a Cessna 404 Titan in Lockhart River: 5 killed

Date & Time: Mar 11, 2020 at 0919 LT
Type of aircraft:
Registration:
VH-OZO
Survivors:
No
Schedule:
Cairns – Lockhart River
MSN:
404-0653
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
3220
Captain / Total hours on type:
399.00
Circumstances:
On 11 March 2020, a Cessna 404 aircraft, registered VH-OZO, was being operated by Air Connect Australia to conduct a passenger charter flight from Cairns to Lockhart River, Queensland. On board were the pilot and 4 passengers, and the flight was being conducted under the instrument flight rules (IFR). Consistent with the forecast, there were areas of cloud and rain that significantly reduced visibility at Lockhart River Airport. On descent, the pilot obtained the latest weather information from the airport’s automated weather information system (AWIS) and soon after commenced an area navigation (RNAV) global satellite system (GNSS) instrument approach to runway 30. The pilot conducted the first approach consistent with the recommended (3°) constant descent profile, and the aircraft kept descending through the minimum descent altitude (MDA) of 730 ft and passed the missed approach point (MAPt). At about 400 ft, the pilot commenced a missed approach. After conducting the missed approach, the pilot immediately commenced a second RNAV GNSS approach to runway 30. During this approach, the pilot commenced descent from 3,500 ft about 2.7 NM prior to the intermediate fix (or 12.7 NM prior to the MAPt). The descent was flown at about a normal 3° flight path, although about 1,000 ft below the recommended descent profile. While continuing on this descent profile, the aircraft descended below the MDA. It then kept descending until it collided with terrain 6.4 km (3.5 NM) short of the runway. The pilot and 4 passengers were fatally injured, and the aircraft was destroyed.
Probable cause:
The accident was the consequence of a controlled flight into terrain.
The following contributing factors were identified:
• While the pilot was operating in the vicinity of Lockhart River Airport, there were areas of cloud and rain that significantly reduced visibility and increased the risk of controlled flight into terrain.
In particular, the aircraft probably entered areas of significantly reduced visibility during the second approach.
• After an area navigation (RNAV) global satellite system (GNSS) approach to runway 30 and missed approach, the pilot immediately conducted another approach to the same runway that was on a similar gradient to the recommended descent profile but displaced about 1,000 ft below that profile. While continuing on this descent profile, the aircraft descended below a segment minimum safe altitude and the minimum descent altitude, then kept descending until the collision with terrain about 6 km before the runway threshold.
• Although the exact reasons for the aircraft being significantly below the recommended descent profile and the continued descent below the minimum descent altitude could not be determined, it was evident that the pilot did not effectively monitor the aircraft’s altitude and descent rate for an extended period.
• When passing the final approach fix (FAF), the aircraft’s lateral position was at about full-scale deflection on the course deviation indicator (CDI), and it then exceeded full-scale deflection for
an extended period. In accordance with the operator’s stabilized approach procedures, a missed approach should have been conducted if the aircraft exceeded half full-scale deflection at the FAF, however a missed approach was not conducted.
• The pilot was probably experiencing a very high workload during periods of the second approach. In addition to the normal high workload associated with a single pilot hand flying an approach in instrument meteorological conditions, the pilot’s workload was elevated due to conducting an immediate entry into the second approach, conducting the approach in a different manner to their normal method, the need to correct lateral tracking deviations throughout the approach, and higher than appropriate speeds in the final approach segment.
• The aircraft was not fitted with a terrain avoidance and warning system (TAWS). Such a system would have provided visual and aural alerts to the pilot of the approaching terrain for an extended period, reducing the risk of controlled flight into terrain.
• Although the aircraft was fitted with a GPS/navigational system suitable for an area navigation (RNAV) global satellite system (GNSS) approach and other non-precision approaches, it was not fitted with a system that provided vertical guidance information, which would have explicitly indicated that the aircraft was well below the recommended descent profile. Although the operator had specified a flight profile for a straight-in approaches and stabilized approach criteria in its operations manual, and encouraged the use of stabilized approaches, there were limitations with the design of these procedures. In addition, there were limitations with other risk controls for minimizing the risk of controlled flight into terrain (CFIT), including no procedures or guidance for the use of the terrain awareness function on the aircraft’s GNS 430W GPS/navigational units and limited monitoring of the conduct of line operations.

Other factors that increased risk:
• Although an applicable height of 1,000 ft for stabilized approach criteria in instrument meteorological conditions has been widely recommended by organizations such as the International Civil Aviation Organization for over 20 years, the Civil Aviation Safety Authority had not provided formal guidance information to Australian operators regarding the content of stabilized approach criteria. (Safety issue)
• The Australian requirements for installing a terrain avoidance and warning system (TAWS) were less than those of other comparable countries for some types of small aeroplanes conducting air transport operations, and the requirements were not consistent with International Civil Aviation Organization (ICAO) standards and recommended practices. More specifically, although there was a TAWS requirement in Australia for turbine-engine aeroplanes carrying 10 or more passengers under the instrument flight rules:
- There was no requirement for piston-engine aeroplanes to be fitted with a TAWS, even though this was an ICAO standard for such aeroplanes authorized to carry 10 or more passengers, and this standard had been adopted as a requirement in many comparable countries.
- There was no requirement for turbine-engine aeroplanes authorized to carry 6–9 passengers to be fitted with a TAWS, even though this had been an ICAO recommended practice since 2007, and this recommended practice had been adopted as a requirement in many comparable countries. (Safety Issue)

Other findings:
• The forecast weather at Lockhart River for the time of the aircraft’s arrival required the pilot to plan for 60 minutes holding or diversion to an alternate aerodrome. The aircraft had sufficient fuel for that purpose; and the aircraft had sufficient fuel to conduct the flight from Cairns to Lockhart River and return, with additional fuel for holding on both sectors if required.
• There was no evidence of any organizational or commercial pressure to conduct the flight to Lockhart River or to complete the flight once to commenced.
• Based on the available evidence, it is very unlikely that the pilot was incapacitated or impaired during the flight.
• There was no evidence of any aircraft system or mechanical anomalies that would have directly influenced the accident. However, as a consequence of extensive aircraft damage, it was not possible to be conclusive about the aircraft’s serviceability.
• The aircraft was fitted with Garmin GNS 430W GPS/navigational units that could be configured to provide visual (but not aural) terrain alerts. However, it could not be determined whether the
terrain awareness function was selected on during the accident flight.
Final Report:

Crash of a Lockheed EC-130Q Hercules near Peak View: 3 killed

Date & Time: Jan 23, 2020 at 1315 LT
Type of aircraft:
Operator:
Registration:
N134CG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Richmond - Richmond
MSN:
4904
YOM:
1981
Flight number:
Bomber 134
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4010
Captain / Total hours on type:
3010.00
Copilot / Total flying hours:
1744
Copilot / Total hours on type:
1364
Aircraft flight hours:
11888
Circumstances:
At about 1205, while B137 was overhead the Adaminaby fire-ground, and about the same time the SAD logged the birddog rejection, B134 departed Richmond as initial attack. On board were the PIC, the copilot and flight engineer. In response to the draft report, the RFS provided excerpts from the state operations controller (SOC) log. An entry was written in the log by the SOC following the accident. The SOC noted having been advised that the birddog had indicated it was ‘not safe to fly’ and that B137 was not returning to the area until the conditions had eased. However, B134 would continue with the PIC to make the ‘decision of safety of bombing operations’. The RFS advised the ATSB that the SOC had the authority to cancel B134’s tasking, but instead allowed it to proceed, with the intention of gathering additional intelligence to assist in determining whether further aerial operations would proceed. The RFS further reported that this indicated an ongoing intelligence gathering and assessment process by the SOC. At about 1235, while returning to Richmond, the PIC of B137 heard the PIC of B134 on the Canberra approach frequency, and contacted them via their designated operating frequency. At that time, B134 was about 112 km north-east of Adaminaby, en route to the fire-ground. In this conversation, the PIC of B137 informed them of the actual conditions and that they would not be returning to Adaminaby. The PIC of B137 reported that they could not recall the specific details of the call, but that the conversation included that they were ‘getting crazy winds’ and ‘you can go take a look’ ’but I am not going back’. It was also noted that the PIC of B134 had asked several questions. It was reported by the majority of the operator’s pilots that, despite receiving information from another pilot, they would have also continued with the tasking under these circumstances, to assess the conditions themselves. At about 1242, the crew of B134 contacted air traffic control to advise them of the coordinates they would be working at, provide an ‘ops normal’ call time, and confirm there was no reported instrument flight rules aircraft in the area. About 5 minutes later, the Richmond ABM also attempted to contact the crew of B134 to confirm ‘ops normal’, firstly by radio, and then by text to the PIC’s mobile phone, but did not receive a response. The automatic dependent surveillance broadcast (ADS-B) data showed that, after arriving at the Adaminaby fire-ground at about 1251, the crew of B134 completed several circuits at about 2,000 ft AGL. At about 1255, the crew advised the Cooma ARO that it was too smoky and windy to complete a retardant drop at that location. The Cooma ARO then provided the crew with the approximate coordinates of the Good Good fire, about 58 km to the east of Adaminaby. The ARO further indicated that they had no specific requirements, but they could look for targets of opportunity, with the objective of conducting structure and property protection near Peak View. At about 1259, the crew of B134 contacted air traffic control to advise that they had been re-tasked to the Good Good fire-ground, and provided updated coordinates. At about the same time, the RFS ground firefighters at the Good Good fire-ground, near Feeney’s Road in Peak View, contacted the Cooma FCC and requested additional assets for property protection. They were advised that a LAT would be passing overhead in about 10 minutes. The firefighters acknowledged the intention of a LAT retardant drop and advised the Cooma FCC they would wait in open country on Feeney’s Road, clear of any properties targeted for protection. At about 1307, B134 arrived overhead the drop area. The drop area was located to the east of a ridgeline, with the fire on the western side of the ridgeline. The aircraft’s recorded track data (SkyTrac) showed that the crew conducted 3 left circuits, at about 1,500 ft, 500 ft and 1,000 ft AGL respectively, prior to commencing the drop circuit. At about 1312, after conducting about 2 circuits, they advised the Cooma ARO of their intention to complete multiple drops on the eastern side of the Good Good fire, and that they would advise the coordinates after the first delivery. At 1315:15, a partial retardant drop was conducted on a heading of about 190°, at about 190 ft AGL (3,600 ft above mean sea level). During the drop, about 1,200 US gallons (4,500 L) of fire retardant was released over a period of about 2 seconds. A ground speed of 144 kt was recorded at the time of the drop. A witness video taken by ground fire-fighters captured the drop and showed the aircraft immediately after the drop in an initial left turn with a positive rate of climb, before it became obscured by smoke. While being intermittently obscured by smoke, the aircraft climbed to about 330 ft AGL (3,770 ft above mean sea level). At about this time, ATSB analysis of the video showed that the aircraft was rolling from about 18° left angle of bank to about a 6° right angle of bank. Following this, the aircraft descended and about 17 seconds after the completion of the partial retardant drop, it was seen at a very low height above the ground, in a slight left bank. Video analysis and accident site examination showed there was no further (emergency) drop of retardant. Throughout this period, the recorded groundspeed increased slightly to a maximum of 151 kt. Shortly after, there was a significant left roll just prior to ground impact. At about 1315:37, the aircraft collided with terrain and a post-impact fuel-fed fire ensued. The 3 crew were fatally injured and the aircraft was destroyed. A review of the Airservices Australia audio recording of the applicable air traffic control frequency found no distress calls were received by controllers prior to the impact.
Probable cause:
The following contributing factors were identified:
- Hazardous weather conditions were forecast and present at the drop site near Peak View, which included strong gusting winds and mountain wave activity, producing turbulence. These
conditions were likely exacerbated by the fire and local terrain.
- The Rural Fire Service continued the B134 tasking to Adaminaby when they learned that no other aircraft would continue to operate due to the environmental conditions. In addition, they relied on the pilot in command to assess the appropriateness of the tasking to Adaminaby without providing them all the available information to make an informed decision on flight safety.
- The pilot in command of B134 accepted the Adaminaby fire-ground tasking, which was in an area of forecast mountain wave activity and severe turbulence. After assessing the conditions as unsuitable, the crew accepted an alternate tasking to continue to the Good Good (Peak View) fire-ground, which was subject to the same weather conditions. The acceptance of these taskings were consistent with company practices.
- Following the partial retardant drop and left turn, the aircraft was very likely subjected to hazardous environmental conditions including low-level windshear and an increased tailwind component, which degraded the aircraft’s climb performance.
- While at a low height and airspeed, it was likely the aircraft aerodynamically stalled, leading to a collision with terrain.
- Coulson Aviation's safety risk management processes did not adequately manage the risks associated with large air tanker operations. There were no operational risk assessments conducted or a risk register maintained. Further, as safety incident reports submitted were mainly related to maintenance issues, operational risks were less likely to be considered or monitored. Overall, this limited their ability to identify and implement mitigations to manage the risks associated with their aerial firefighting operations. (Safety issue)
- Coulson Aviation did not provide a pre-flight risk assessment for their firefighting large air tanker crews. This would provide predefined criteria to ensure consistent and objective decision-making with accepting or rejecting tasks, including factors relating to crew, environment, aircraft and external pressures. (Safety issue)
- The New South Wales Rural Fire Service had limited large air tanker policies and procedures for aerial supervision requirements and no procedures for deployment without aerial supervision.(Safety issue)
- The New South Wales Rural Fire Service did not have a policy or procedures in place to manage task rejections, nor to communicate this information internally or to other pilots working in the same area of operation. (Safety issue)

Other factors that increased risk:
- The B134 crew were very likely not aware that the 'birddog' pilot had declined the tasking to Adaminaby fire-ground, and the smaller fire-control aircraft had ceased operations in the area, due to the hazardous environmental conditions
- In the limited time available, the remainder of the fire-retardant load was not jettisoned prior to the aircraft stalling.
- Coulson Aviation did not include a windshear recovery procedure or scenario in their C-130 Airplane Flight Manual and annual simulator training respectively, to ensure that crews consistently and correctly responded to a windshear encounter with minimal delay. (Safety issue)
- Coulson Aviation fleet of C-130 aircraft were not fitted with a windshear detection system, which increased the risk of a windshear encounter and/or delayed response to a windshear encounter during low level operations. (Safety issue)
- The New South Wales Rural Fire Service procedures allowed operators to determine when pilots were initial attack capable. However, they intended for the pilot in command to be certified by the United States Department of Agriculture Forest Service certification process. (Safety issue)

Other findings:
- The aircraft's cockpit voice recorder did not record the accident flight, which resulted in a valuable source of safety information not being available. This limited the extent to which potential factors contributing to the accident could be identified.
Final Report:

Crash of an Angel Aircraft Corporation Model 44 Angel in Mareeba: 2 killed

Date & Time: Dec 14, 2019 at 1115 LT
Registration:
VH-IAZ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mareeba - Mareeba
MSN:
004
YOM:
2008
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
20000
Captain / Total hours on type:
300.00
Copilot / Total flying hours:
5029
Copilot / Total hours on type:
0
Aircraft flight hours:
1803
Circumstances:
On 14 December 2019, at 1046 Eastern Standard Time, an Angel Aircraft Corporation Model 44 aircraft, registered VH-IAZ, commenced taxiing at Mareeba Airport, Queensland. On board the aircraft were two pilots. The pilot in the left seat (‘the pilot’) owned the aircraft and was undertaking a flight review, which was being conducted by the Grade 1 flight instructor in the right seat (‘the instructor’). The planned flight was to operate in the local area, as a private flight and under visual flight rules. As the aircraft taxied towards the runway intersection, the pilot broadcast on the common traffic advisory frequency (CTAF) that VH-IAZ was taxiing for runway 28. The pilot made another broadcast when entering and backtracking the runway, then at 1058, broadcast that the aircraft had commenced the take-off roll. Witnesses who heard the aircraft during the take-off reported that it sounded like one of the engines was hesitating and misfiring. An aircraft maintainer who observed the aircraft take off, reported seeing black sooty smoke trailing from the right engine. The maintainer then watched the aircraft climb slowly and turn right towards the north. Another witness who heard the aircraft in flight soon afterwards, reported that it sounded normal for that aircraft, which had a distinctive sound because the engines’ exhaust gases pass through the propellers. Once airborne, the pilot broadcast that they were ‘making a low-level right-hand turn and then climbing up to not above 4,500 [feet] for the south-west training area.’ About 2 minutes later, the instructor broadcast that they were just to the west of the airfield in the training area at 2,500 ft and on climb to 4,000 ft, and communicated with a helicopter pilot operating in the area. After 8 minutes in the training area, the pilot broadcast that they were inbound to the aerodrome. At 1112, the aircraft’s final transmission was broadcast by the pilot, advising that they were joining the crosswind circuit leg for runway 28. Witnesses then saw the aircraft touch down on the runway and continue to take off again, consistent with a ‘touch-and-go’ manoeuvre, and heard one engine ‘splutter’ as the aircraft climbed to an estimated 100–150 ft above ground level. At about 1115, the aircraft was observed overhead a banana plantation beyond the end of the runway, banked to the right in a descending turn, before it suddenly rolled right. Witnesses observed the right wing drop to near vertical and the aircraft impacted terrain in a cornfield. Both pilots were fatally injured and the aircraft was destroyed.
Probable cause:
Contributing factors:
• The flight instructor very likely conducted a simulated engine failure after take-off in environmental conditions and a configuration in which the aircraft was unable to maintain altitude with one engine inoperative.
• Having not acted quickly to restore power to the simulated inoperative engine, the pilots did not reduce power and land ahead (in accordance with the Airplane Flight Manual procedure) before the combination of low airspeed and bank angle resulted in a loss of directional control at a height too low to recover.
• The instructor had very limited experience with the aircraft type, and with limited preparation for the flight, was likely unaware of the landing gear and flap retraction time and the extent of their influence on performance with one engine inoperative.

Other factors that increased risk:
• The pilot had not flown for 3 years prior to the accident flight, which likely resulted in a decay in skills at managing tasks such as an engine failure after take-off and in decision-making ability. The absence of flying practice before the flight review probably affected the pilot’s ability to manage the asymmetric low-level flight.
• The aircraft had not been flown for more than 2 years and had not been stored in accordance with the airframe and engine manufacturers’ recommendations. This very likely resulted in some of the right engine cylinders running with excessive fuel to air ratio for complete combustion and may also have reduced the expected service life of both engines’ components.
• The right-side altimeter was probably set to an incorrect barometric pressure, resulting in it over-reading the aircraft’s altitude by about 90 ft.
Final Report:

Crash of a Britten-Norman BN-2A-20 Islander in West Portal: 1 killed

Date & Time: Dec 8, 2018 at 0828 LT
Type of aircraft:
Operator:
Registration:
VH-OBL
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Cambridge – Bathurst Harbour
MSN:
2035
YOM:
1986
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
540
Captain / Total hours on type:
80.00
Aircraft flight hours:
12428
Circumstances:
On 8 December 2018, the pilot of a Pilatus Britten-Norman BN2A-20 Islander, registered VH-OBL and operated by Airlines of Tasmania, was conducting a positioning flight under the visual flight rules from Cambridge Airport to the Bathurst Harbour aeroplane landing area (ALA), Tasmania. The aircraft departed Cambridge at about 0748 Eastern Daylight-saving Time and was scheduled to arrive at Bathurst Harbour about 0830 to pick up five passengers for the return flight. The passengers were part of a conservation project that flew to south-west Tasmania regularly, and it was the pilot’s only flight for that day. Automatic dependent surveillance broadcast (ADS-B) position and altitude data (refer to the section titled Recorded information) showed the aircraft tracked to the south-west towards Bathurst Harbour (Figure 1). At about 0816, the aircraft approached a gap in the Arthur Range known as ‘the portals’. The portals are a saddle (lowest area) between the Eastern and Western Arthur Range, and was an optional route that Airlines of Tasmania used between Cambridge and Bathurst Harbour when the cloud base prevented flight over the mountain range. After passing through the portals, the aircraft proceeded to conduct a number of turns below the height of the surrounding highest terrain. The final data point recorded was at about At about 0829, the Australian Maritime Safety Authority received advice that an emergency locator transmitter allocated to VH-OBL had activated. They subsequently advised the Tasmanian Police and the aircraft operator of the activation, and initiated search and rescue efforts. The rescue efforts included two helicopters and a Challenger 604 search and rescue jet aircraft. The Challenger arrived over the emergency locator transmitter signal location at around 0925, however, due to cloud cover the crew were unable to visually identify the precise location of VH-OBL. A police rescue helicopter arrived at the search area at about 1030. The pilot of that helicopter reported observing cloud covering the eastern side of the Western Arthur Range, and described a wall of cloud with its base sitting on the bottom of the west portal. Multiple attempts were made throughout the day to locate the accident site, however, due to low-level cloud, and fluctuating weather conditions, the search and rescue operation was unable to confirm visual location of the aircraft until about 1900. The aircraft wreckage was found in mountainous terrain of the Western Arthur Range in the Southwest National Park (Figure 2) . The search and rescue crew assessed that the accident was unlikely to have been survivable. The helicopter crew considered winching personnel to the site, however, due to a number of risks, including potential for cloud reforming, the time of day and lighting, and other hazards associated with the mountainous location, the helicopter departed the area. The aircraft wreckage was accessed the following day, when it was confirmed that the pilot was fatally injured.
Probable cause:
From the evidence available, the following findings are made with respect to the controlled flight into terrain involving Pilatus Britten-Norman BN2A, VH-OBL, 101 km west-south-west of Hobart, Tasmania, on 8 December 2018.
Contributing factors:
• The pilot continued descending over the Arthur Range saddle to a lower altitude than previous flights, likely due to marginal weather. This limited the options for exiting the valley surrounded
by high terrain.
• While using a route through the Arthur Range due to low cloud conditions, the pilot likely encountered reduced visual cues in close proximity to the ground, as per the forecast conditions. This led to controlled flight into terrain while attempting to exit the range.
Final Report:

Crash of a Boeing 737-8BK off Weno Island: 1 killed

Date & Time: Sep 28, 2018 at 0924 LT
Type of aircraft:
Operator:
Registration:
P2-PXE
Survivors:
Yes
Schedule:
Kolonia – Chuuk – Port Moresby
MSN:
33024/1688
YOM:
2005
Flight number:
PX073
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
35
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
19780
Captain / Total hours on type:
2276.00
Copilot / Total flying hours:
4618
Copilot / Total hours on type:
368
Aircraft flight hours:
37160
Aircraft flight cycles:
14788
Circumstances:
On 28 September 2018, at 23:24:19 UTC2 (09:24 local time), a Boeing 737-8BK aircraft, registered P2-PXE (PXE), operated by Air Niugini Limited, was on a scheduled passenger flight number PX073, from Pohnpei to Chuuk, in the Federated States of Micronesia (FSM) when, during its final approach, the aircraft impacted the water of the Chuuk Lagoon, about 1,500 ft (460 m) short of the runway 04 threshold. The aircraft deflected across the water several times before it settled in the water and turned clockwise through 210 deg and drifted 460 ft (140 m) south east of the runway 04 extended centreline, with the nose of the aircraft pointing about 265°. The pilot in command (PIC) was the pilot flying, and the copilot was the support/monitoring pilot. An Aircraft Maintenance Engineer occupied the cockpit jump seat. The engineer videoed the final approach on his iPhone, which predominantly showed the cockpit instruments. Local boaters rescued 28 passengers and two cabin crew from the left over-wing exits. Two cabin crew, the two pilots and the engineer were rescued by local boaters from the forward door 1L. One life raft was launched from the left aft over-wing exit by cabin crew CC5 with the assistance of a passenger. The US Navy divers rescued six passengers and four cabin crew and the Load Master from the right aft over-wing exit. All injured passengers were evacuated from the left over-wing exits. One passenger was fatally injured, and local divers located his body in the aircraft three days after the accident. The Government of the Federated States of Micronesia commenced the investigation and on 14th February 2019 delegated the whole of the investigation to the PNG Accident Investigation Commission. The investigation determined that the flight crew’s level of compliance with Air Niugini Standard Operating Procedures Manual (SOPM) was not at a standard that would promote safe aircraft operations. The PIC intended to conduct an RNAV GPS approach to runway 04 at Chuuk International Airport and briefed the copilot accordingly. The descent and approach were initially conducted in Visual Meteorological Conditions (VMC), but from 546 ft (600 ft)4 the aircraft was flown in Instrument Meteorological Conditions (IMC). The flight crew did not adhere to Air Niugini SOPM and the approach and pre-landing checklists. The RNAV (GPS) Rwy 04 Approach chart procedure was not adequately briefed. The RNAV approach specified a flight path descent angle guide of 3º. The aircraft was flown at a high rate of descent and a steep variable flight path angle averaging 4.5º during the approach, with lateral over-controlling; the approach was unstabilised. The Flight Data Recorder (FDR) recorded a total of 17 Enhanced Ground Proximity Warning System (EGPWS) alerts, specifically eight “Sink Rate” and nine “Glideslope”. The recorded information from the Cockpit Voice Recorder (CVR) showed that a total of 14 EGPWS aural alerts sounded after passing the Minimum Descent Altitude (MDA), between 307 ft (364 ft) and the impact point. A “100 ft” advisory was annunciated, in accordance with design standards, overriding one of the “Glideslope” aural alert. The other aural alerts were seven “Glideslope” and six “Sink Rate”. The investigation observed that the flight crew disregarded the alerts, and did not acknowledge the “minimums” and 100 ft alerts; a symptom of fixation and channelised attention. The crew were fixated on cues associated with the landing and control inputs due to the extension of 40° flap. Both pilots were not situationally aware and did not recognise the developing significant unsafe condition during the approach after passing the Missed Approach Point (MAP) when the aircraft entered a storm cell and heavy rain. The weather radar on the PIC’s Navigation Display showed a large red area indicating a storm cell immediately after the MAP, between the MAP and the runway. The copilot as the support/monitoring pilot was ineffective and was oblivious to the rapidly unfolding unsafe situation. He did not recognise the significant unsafe condition and therefore did not realise the need to challenge the PIC and take control of the aircraft, as required by the Air Niugini SOPM. The Air Niugini SOPM instructs a non-flying pilot to take control of the aircraft from the flying pilot, and restore a safe flight condition, when an unsafe condition continues to be uncorrected. The records showed that the copilot had been checked in the Simulator for EGPWS Alert (Terrain) however there was no evidence of simulator check sessions covering the vital actions and responses required to retrieve a perceived or real situation that might compromise the safe operation of the aircraft. Specifically sustained unstabilised approach below 1,000 ft amsl in IMC. The PIC did not conduct the missed approach at the MAP despite the criteria required for visually continuing the approach not being met, including visually acquiring the runway or the PAPI. The PIC did not conduct a go around after passing the MAP and subsequently the MDA although:
• The aircraft had entered IMC;
• the approach was unstable;
• the glideslope indicator on the Primary Flight Display (PFD) was showing a rapid glideslope deviation from a half-dot low to 2-dots high within 9 seconds after passing the MDA;
• the rate of descent high (more than 1,000 ft/min) and increasing;
• there were EGPWS Sink Rate and Glideslope aural alerts; and
• the EGPWS visual PULL UP warning message was displayed on the PFD.
The report highlights that deviations from recommended practice and SOPs are a potential hazard, particularly during the approach and landing phase of flight, and increase the risk of approach and landing accidents. It also highlights that crew coordination is less than effective if crew members do not work together as an integrated team. Support crew members have a duty and responsibility to ensure that the safety of a flight is not compromised by non-compliance with SOPs, standard phraseology and recommended practices. The investigation found that the Civil Aviation Safety Authority of PNG (CASA PNG) policy and procedures of accepting manuals rather than approving manuals, while in accordance with the Civil Aviation Rules requirements, placed a burden of responsibility on CASA PNG as the State Regulator to ensure accuracy and that safety standards are met. In accepting the Air Niugini manuals, CASA PNG did not meet the high standard of evidence-based assessment required for safety assurance, resulting in numerous deficiencies and errors in the Air Niugini Operational, Technical, and Safety manuals as noted in this report and the associated Safety Recommendations. The report includes a number of recommendations made by the AIC, with the intention of enhancing the safety of flight (See Part 4 of this report). It is important to note that none of the safety deficiencies brought to the attention of Air Niugini caused the accident. However, in accordance with Annex 13 Standards, identified safety deficiencies and concerns must be raised with the persons or organisations best placed to take safety action. Unless safety action is taken to address the identified safety deficiencies, death or injury might result in a future accident. The AIC notes that Air Niugini Limited took prompt action to address all safety deficiencies identified by the AIC in the 12 Safety Recommendations issued to Air Niugini, in an average time of 23 days. The quickest safety action being taken by Air Niugini was in 6 days. The AIC has closed all 12 Safety Recommendations issued to Air Niugini Limited. One safety concern prompting an AIC Safety Recommendation was issued to Honeywell Aerospace and the US FAA. The safety deficiency/concern that prompted this Safety Recommendation may have been a contributing factor in this accident. The PNG AIC is in continued discussion with the US NTSB, Honeywell, Boeing and US FAA. This recommendation is the subject of ongoing research and the AIC Recommendation will remain ACTIVE pending the results of that research.
Probable cause:
The flight crew did not comply with Air Niugini Standard Operating Procedures Manual (SOPM) and the approach and pre-landing checklists. The RNAV (GPS) Rwy 04 Approach chart procedure was not adequately briefed. The aircraft’s flight path became unstable with lateral over-controlling commencing shortly after autopilot disconnect at 625 ft (677 ft). From 546 ft (600 ft) the aircraft was flown in Instrument Meteorological Conditions (IMC) and the rate of descent significantly exceeded 1,000 feet/min in Instrument Meteorological Conditions (IMC) from 420 ft (477 ft). The flight crew heard, but disregarded, 13 EGPWS aural alerts (Glideslope and Sink Rate), and flew a 4.5º average flight path (glideslope). The pilots lost situational awareness and their attention was channelised or fixated on completing the landing. The PIC did not execute the missed approach at the MAP despite: PAPI showing 3 whites just before entering IMC; the unstabilised approach; the glideslope indicator on the PFD showing a rapid glideslope deviation from half-dot low to 2-dots high within 9 seconds after passing the MDA; the excessive rate of descent; the EGPWS aural alerts: and the EGPWS visual PULL UP warning on the PFD. The copilot (support/monitoring pilot) was ineffective and was oblivious to the rapidly unfolding unsafe situation. It is likely that a continuous “WHOOP WHOOP PULL UP”70 hard aural warning, simultaneously with the visual display of PULL UP on the PFD (desirably a flashing visual display PULL UP on the PFD), could have been effective in alerting the crew of the imminent danger, prompting a pull up and execution of a missed approach, that may have prevented the accident.
Final Report:

Crash of a De Havilland DHC-2 Beaver off Cottage Point: 6 killed

Date & Time: Dec 31, 2017 at 1515 LT
Type of aircraft:
Operator:
Registration:
VH-NOO
Flight Phase:
Survivors:
No
Schedule:
Cottage Point - Sydney
MSN:
1535
YOM:
1963
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
10762
Aircraft flight hours:
21872
Circumstances:
On 31 December 2017, at about 1045 Eastern Daylight-saving Time, five passengers arrived via water-taxi at the Sydney Seaplanes terminal, Rose Bay, New South Wales (NSW) for a charter fly-and-dine experience to a restaurant at Cottage Point on the Hawkesbury River. Cottage Point is about 26 km north of Sydney Harbour in the Ku-ring-gai Chase National Park, a 20 minute floatplane flight from Rose Bay. At about 1130, prior to boarding the aircraft, the passengers received a pre-flight safety briefing. At about 1135, the pilot and five passengers departed the Rose Bay terminal for the flight to Cottage Point via the northern beaches coastal route, in a de Havilland Canada DHC-2 Beaver floatplane, registered VH-NOO and operated by Sydney Seaplanes. The flight arrived at Cottage Point just before midday and the passengers disembarked. The pilot then conducted another four flights in VH-NOO between Cottage Point and Rose Bay. The pilot arrived at Cottage Point at about 1353. After securing the aircraft at the pontoon and disembarking passengers from that flight, the pilot walked to a kiosk at Cottage Point for a drink and food. At about 1415, the pilot received a phone call from the operator via the kiosk, asking the pilot to move the aircraft off the pontoon, which could only accommodate one aircraft at a time. This was to allow the pilot of the operator’s other DHC-2 aircraft (VH-AAM) to pick-up other restaurant passengers. The pilot of VH-NOO immediately returned to the aircraft and taxied away from the pontoon into Cowan Creek. The operator’s records indicated that VH-AAM arrived at the pontoon and shut down the engine at about 1419, and subsequently departed at about 1446. The pilot of VH-NOO returned to the pontoon after having taxied in Cowan Creek with the engine running for up to 27 minutes, while waiting for the other aircraft. During the taxi, closed-circuit television footage from a private residence at Cottage Point showed VH-NOO at 1444, with the pilot’s door ajar. After shutting down the aircraft, the pilot briefly went into the restaurant to see if the passengers were ready to leave, and then returned to the aircraft. The return flight to Rose Bay, scheduled to depart at 1500, provided sufficient time for the passengers to meet a previously booked water-taxi to transport them from Rose Bay to their hotel at 1545. At about 1457, the passengers commenced boarding the aircraft and at around 1504, the aircraft had commenced taxiing toward the designated take-off area in Cowan Creek. At about 1511, the aircraft took off towards the north-north-east in Cowan Creek, becoming airborne shortly before passing Cowan Point. The aircraft climbed straight ahead before commencing a right turn into Cowan Water. A witness, who was travelling east in a boat on the northern side of Cowan Water, photographed the aircraft passing over a location known as ‘Hole in the wall’. These photographs indicated that the aircraft was turning to the right with a bank angle of 15-20°. Witnesses observed the right turn continue above Little Shark Rock Point and Cowan Water. The last photograph taken by the passenger was when the aircraft was heading in a southerly direction towards Cowan Bay. At that time, the aircraft was estimated to be at an altitude of about 30 m (98 ft).Shortly after the turn in Cowan Water, several witnesses observed the aircraft heading directly towards and entering Jerusalem Bay flying level or slightly descending, below the height of the surrounding terrain. Witnesses also reported hearing the aircraft’s engine and stated that the sound was constant and appeared normal. About 1.1 km after entering Jerusalem Bay, near the entrance to Pinta Bay, multiple witnesses reported seeing the aircraft flying along the southern shoreline before it suddenly entered a steep right turn at low-level. Part-way through the turn, the aircraft’s nose suddenly dropped before the aircraft collided with the water, about 95 m from the northern shore and 1.2 km from the end of Jerusalem Bay. The aircraft came to rest inverted and with the cabin submerged. A number of people on watercraft who heard or observed the impact, responded to render assistance. Those people could not access the (underwater) aircraft cabin. The entire tail section and parts of both floats were initially above the waterline, but about 10 minutes later had completely submerged. The pilot and five passengers received fatal injuries.
Probable cause:
Contributing factors:
- The aircraft entered Jerusalem Bay, a known confined area, below terrain height with a level or slightly descending flight path. There was no known operational need for the aircraft to be
operating in the bay.
- While conducting a steep turn in Jerusalem Bay, it was likely that the aircraft aerodynamically stalled at an altitude too low to effect a recovery before colliding with the water.
- It was almost certain that there was elevated levels of carbon monoxide in the aircraft cabin, which resulted in the pilot and passengers having higher than normal levels of carboxyhaemoglobin in their blood.
- Several pre-existing cracks in the exhaust collector ring, very likely released exhaust gas into the engine/accessory bay, which then very likely entered the cabin through holes in the main
firewall where three bolts were missing.
- A 27 minute taxi before the passengers boarded, with the pilot’s door ajar likely exacerbated the pilot’s elevated carboxyhaemoglobin level.
- It was likely that the pilot's ability to safely operate the aircraft was significantly degraded by carbon monoxide exposure.
- Disposable chemical spot detectors, commonly used in general aviation, can be unreliable at detecting carbon monoxide in the aircraft cabin. Further, they do not draw a pilot's attention to a hazardous condition, instead they rely on the pilot noticing the changing colour of the sensor.
- There was no regulatory requirement from the Civil Aviation Safety Authority for piston-engine aircraft to carry a carbon monoxide detector with an active warning to alert pilots to the presence of elevated levels of carbon monoxide in the cabin. (Safety issue)

Other factors that increased risk:
- It was likely that the effectiveness of the disposable carbon monoxide chemical spot detector fitted to the aircraft was reduced due to sun bleaching.
- Although detectors were not required to be fitted to their aircraft, Sydney Seaplanes had no mechanism for monitoring the serviceability of the carbon monoxide detectors. (Safety issue)
- The in situ bolts used by the maintenance organisation to secure the magneto access panels on the main firewall were worn, and were a combination of modified AN3-3A bolts and non-specific bolts. This increased the risk of the bolts either not tightening securely on installation and/or coming loose during operations.
- The operator relied on volunteered passenger weights without allowances for variability, rather than actual passenger weights obtained just prior to a flight. This increased the risk of underestimating passenger weights and potentially overloading an aircraft.
- The standard passenger weights specified in Civil Aviation Advisory Publication (CAAP) 235-1(1) Standard passenger and baggage weights did not accurately reflect the average weights of the current Australian population. Further, the CAAP did not provide guidance on the use of volunteered passenger weights as an alternative to weights derived just prior to a flight.
- Australian civil aviation regulations did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and other accidents, have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in the non-identification of safety issues, which continue to present a hazard to current and future passengercarrying operations. (Safety issue)
- Annex 6 to the Convention of International Civil Aviation did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and numerous other accidents have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in important safety issues not being identified, which may remain a hazard to current and future passenger carrying operations. (Safety issue)

Other findings:
- It was very likely that the middle row right passenger did not have his seatbelt fastened at the time of impact, however, the reason for this could not be determined.
- The accident was not survivable due to the combination of the impact forces and the submersion of the aircraft.
- The pilot had no known pre-existing medical conditions that could explain the accident.
Final Report:

Crash of a Britten-Norman BN-2A Islander in Saidor Gap: 1 killed

Date & Time: Dec 23, 2017 at 1010 LT
Type of aircraft:
Operator:
Registration:
P2-ISM
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Derim - Lae
MSN:
227
YOM:
1970
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1982
Captain / Total hours on type:
139.00
Aircraft flight hours:
32232
Circumstances:
On 23 December 2017, at 00:10 UTC (10:10 local), a Britten Norman BN-2A Islander aircraft, registered P2-ISM (ISM), owned and operated by North Coast Aviation, impacted a ridge, at about 9,500 ft (6°11'29"S, 146°46'11"E) that runs down towards the Sapmanga Valley from the Sarawaget Ranges, Morobe Province. The pilot elected to track across the Sarawaget ranges (See figure 1), from Derim Airstrip to Nadzab Airport, Morobe Province, not above 10,000 ft. The track flown from Derim was to the northwest 6.5 nm (12 km) to a point 0.8 nm (1.5 km) westsouthwest of Yalumet Airstrip where the aircraft turned southwest to track to the Saidor Gap. GPS recorded track data immediately prior to the last GPS fix showed that the aircraft was on a shallow descent towards the ridge. The aircraft impacted the ridge about 150 m beyond the last fix. There were no reports of a transmission of an ELT distress signal. During the search for the aircraft, what appeared to be the right aileron was found hanging from a tree near the top of the heavily-timbered, densely-vegetated ridge. The remainder of the wreckage was found about 130 m from the aileron along the projected track. The aircraft impacted the ground in a steep nose-down, right wing-low attitude. The majority of the aircraft wreckage was contained at the ground impact point. The aircraft was destroyed by impact forces. The pilot, the sole occupant, who initially survived, was reported deceased by the rescue team on 27 December 2017 at 22:10. The pilot had made contact with one of the operator’s pilots at 16:15 on 23 December. The pilot’s time of death, recorded on the Death Certificate, was 10:40 am local on 24 December. Rescuers felled trees on the steep heavily timbered, densely vegetated slope about 20 metres from the wreckage and constructed a helipad.
Probable cause:
Cloud build up along the pilot’s chosen route may have forced him to manoeuvre closer than normal to the ridge, in order to avoid flying into the cloud. The aircraft’s right wing struck a tree protruding from the forest canopy during controlled flight into terrain. It is likely that the right aileron mass balance became snagged on the tree and rapidly dislodged the aileron from the wing. The loss of roll control, and the aerodynamic differential, forced the aircraft to descend steeply through the forest and impacted terrain.
Final Report:

Crash of a Pacific Aerospace FU-24 Stallion in Upper Turon: 1 killed

Date & Time: Jun 16, 2017 at 1049 LT
Type of aircraft:
Registration:
VH-EUO
Flight Phase:
Survivors:
No
Schedule:
Upper Turon - Upper Turon
MSN:
3002
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4688
Captain / Total hours on type:
786.00
Aircraft flight hours:
11059
Circumstances:
On 16 June 2017, a Pacific Aerospace Ltd FU24 Stallion, registered VH-EUO (EUO), was conducting aerial agricultural operations from a private airstrip at Redhill, 36 km north-north-east of Bathurst, New South Wales (NSW). The operations planned for that day involved the aerial application of fertiliser on three properties in the Upper Turon area of NSW. At about 0700 Eastern Standard Time on the morning of the accident, the pilot and loader drove to Bathurst Airport to fill the fuel tanker and then continued to the worksite at the Redhill airstrip in the Upper Turon area, arriving at about 0830. Work on the first property started at about 0900, with the first flight of the day commencing at 0920. Work on the first property continued until 1350 with two refuelling stops at 1048 and 1250. Approximately 40 tonnes of fertiliser was applied on the first job. In preparation for the second job, fertiliser and seed were loaded into the aircraft and maps of the second job area were passed to the pilot. At 1357, the aircraft took off for the first flight of the second job. The aircraft returned to reload, and at 1405 the aircraft took off for the second flight. A short time later, at 14:06:59, recorded flight data from the aircraft ceased. When the aircraft did not return as expected, the loader radioed the pilot. When the loader could not raise the pilot on the radio, he became concerned and drove his vehicle down the airstrip to see if the aircraft had experienced a problem on the initial climb. Finding no sign of the aircraft, he returned to the load site, while continuing to call the pilot on the radio. He then drove to the application area to search for the aircraft before returning to the load site. With no sign of the aircraft, the loader called emergency services to raise the alarm. By about 1500, police had arrived on site and a ground search commenced. A police helicopter also joined the search, which was eventually called off due to low light. The next morning, at about 0630, the search recommenced and included NSW Police State Emergency Service personnel, and local volunteers. At about 0757, the wreckage of the aircraft was found in dense bush on the side of a hill to the east of the application area. The pilot was found deceased in the aircraft. The aircraft was found approximately 17 hours after the last recorded flight data and there were no witnesses to the accident.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain involving a FU24 Stallion, VH-EUO 40 km north-east of Bathurst, New South Wales on 16 June 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing factors:
- The pilot flew the aircraft into an area of rising terrain that was outside the normal operating area for this job site.
- For reasons that could not be determined, the aircraft aerodynamically stalled and collided with terrain during re-positioning at the end of the application run.
Other findings:
- There was no evidence of any defect with the aircraft that would have contributed to the loss of control.
Final Report: