Crash of a Beechcraft C90 King Air in Toowoomba: 4 killed

Date & Time: Nov 27, 2001 at 0837 LT
Type of aircraft:
Operator:
Registration:
VH-LQH
Flight Phase:
Survivors:
No
Schedule:
Toowoomba – Goondiwindi
MSN:
LJ-644
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3693
Captain / Total hours on type:
385.00
Aircraft flight hours:
6931
Circumstances:
On 25 June 2004, the Australian Transport Safety Bureau released its final investigation report into an accident which occurred on 27 November 2001 at Toowoomba aerodrome, Qld, involving a Beech Aircraft Corporation King Air C90 aircraft, registered VH-LQH, which experienced an engine failure shortly after takeoff. The aircraft was destroyed and all four occupants sustained fatal injuries.
Probable cause:
In light of a further review of the evidence, the ATSB has reconsidered its original finding that the initiating event of the engine failure of VH-LQH was a blade release in the compressor turbine and proposes that an alternative possibility could have been that the initiating event occurred in the power turbine. Notwithstanding this possibility, in either scenario, the remainder of the findings and safety recommendations contained in the original ATSB report are still relevant.
Final Report:

Crash of an Antonov AN-12BP in Honiara

Date & Time: Oct 16, 2001
Type of aircraft:
Operator:
Registration:
ER-ADT
Flight Type:
Survivors:
Yes
Schedule:
Brisbane - Honiara
MSN:
2 3 406 05
YOM:
1962
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful cargo flight from Brisbane, the crew started the approach to Honiara-Henderson Airport. On final approach, the four engine airplane was too low when the right main gear struck the sea and was torn off. The crew increased engine power, continued the approach and completed the landing on runway 24. After touchdown, the aircraft went out of control, veered off runway at high speed and came to rest. All six occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Fletcher FU-24-950M in Waiotira

Date & Time: Sep 8, 2001 at 0710 LT
Type of aircraft:
Operator:
Registration:
ZK-CMN
Flight Phase:
Survivors:
Yes
Schedule:
Waiotira - Waiotira
MSN:
118
YOM:
1966
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15131
Captain / Total hours on type:
14935.00
Circumstances:
The aircraft was flown to a farm airstrip then loaded with a small load of agricultural product. A combination of extremely soft airstrip conditions, a quartering tailwind, and underslung spreader equipment, degraded performance to the extent that the aircraft was unable to become airborne within the available length of the strip. The load was jettisoned, but the aircraft struck a fence and scraped the ground with the left wing tip and aileron. The aircraft did become airborne, but was unable to be effectively controlled and subsequently struck the ground. The aircraft was destroyed and the pilot was seriously injured.
Probable cause:
A combination of extremely soft airstrip conditions, a quartering tailwind, and underslung spreader equipment, degraded performance to the extent that the aircraft was unable to become airborne within the available length of the strip.

Crash of a Partenavia P.68B in North Shore

Date & Time: Jul 20, 2001 at 0459 LT
Type of aircraft:
Operator:
Registration:
ZK-DMA
Flight Type:
Survivors:
Yes
Schedule:
Auckland-Whangarei
MSN:
68
YOM:
1976
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
706
Captain / Total hours on type:
200.00
Aircraft flight hours:
4773
Circumstances:
On Friday 20 July 2001, at around 0450, Partenavia P68B ZK-DMA was abeam North Shore Aerodrome at 5000 feet in darkness and enroute to Whangarei, when it suffered a double engine power loss. The pilot made an emergency landing on runway 21 at North Shore Aerodrome, but the aircraft overran the end of the runway, went through a fence, crossed a road and stopped in another fence. The pilot was the only person on board the aircraft and received face and ankle injuries. The aircraft encountered meteorological conditions conducive to engine intake icing, and ice, hail or sleet probably blocked the engine air intakes. The pilot had probably developed a mindset that dismissed icing as a cause, and consequently omitted to use alternate engine intake air, which should have restored engine power.
Probable cause:
The following findings were identified:
- The pilot was suitably qualified and authorised to conduct the flight.
- The aircraft was airworthy and its records indicated it had been maintained correctly.
- The aircraft encountered weather conditions conducive to the formation of engine intake icing.
- The engine air intakes probably became blocked by sleet, ice or hail, which caused both engines to lose power.
- The pilot probably developed a mindset that dismissed engine intake icing as a cause of the double engine power loss and omitted to apply the necessary corrective action.
- Had the pilot selected each engine’s alternate engine intake air on, engine power should have been restored.
- The Partenavia P68B flight manual warning concerning the use of alternate engine intake air should be amended to require the in-flight use of alternate air at ambient temperatures above freezing, in a high-humidity environment.
Final Report:

Crash of an Embraer EMB-110P1 Bandeirante in Cootamundra

Date & Time: Jun 25, 2001 at 1021 LT
Operator:
Registration:
VH-OZG
Survivors:
Yes
Schedule:
Sydney – Griffith
MSN:
110-241
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6850
Captain / Total hours on type:
253.00
Circumstances:
The Embraer EMB-110P1 Bandeirante, VH-OZG, departed from Sydney Kingsford Smith international airport at 0855 on 25 June 2001, on a single-pilot instrument flight rules (IFR) charter flight to Griffith. The nine occupants on board the aircraft included the pilot and eight passengers. At about 0945, while maintaining an altitude of 10,000 ft, the master caution light illuminated. At the same time, the multiple alarm panel ‘GENERATOR 2’ (right generator) warning light also illuminated, indicating that the generator was no longer supplying power to the main electrical bus bar. After resetting the generator and monitoring its output, the pilot was satisfied that it was operating normally. A short time later, the master warning light illuminated again. A number of circuit breakers tripped, accompanied by multiple master alarm panel warnings. The red ‘FIRE’ warning light on the right engine fire extinguisher ‘T’ handle also illuminated, accompanied by the aural fire alarm warning. The pilot reported that after silencing the aural fire alarm, he carried out the engine fire emergency checklist actions. However, he was unable to select the fuel cut-off position with the right fuel condition lever, despite overriding the locking mechanism using his left thumb while attempting to operate the lever with his right hand. He also reported that the propeller lever did not remain in the feathered detent, but moved forward, as if spring-loaded, to an intermediate position. After unsuccessfully attempting to select fuel cut-off with the right fuel condition lever, or feather the right propeller with the propeller lever, the pilot pulled the right ‘T’ handle to discharge the fire bottle. The amber discharge light illuminated and a short time later the fire alarm sounded again. Passengers reported seeing lights illuminated on the multiple alarm panel and heard the sound of a continuous fire alarm in the cockpit. At 0956, the pilot notified air traffic services (ATS) that there was a ‘problem’ with the aircraft, but did not specify the nature of that problem. Almost immediately the pilot transmitted a PAN radio call and advised ATS that there was a fire on board the aircraft. The nearest aerodromes for an emergency landing were not available due to fog, and the pilot decided to divert to Young, which was about 35 NM to the south east of the aircraft’s position at that time. The pilot advised ATS that the fire was extinguished, and that he was diverting the aircraft to Young. Two minutes later, the pilot repeated his advice to ATS stating that a fire in the right engine had been extinguished, and requested emergency services for the aircraft’s arrival at Young. The pilot informed one of the passengers that there was an engine fire warning, and that they would be landing at Young. The passengers subsequently reported seeing flames in the right engine nacelle and white smoke streaming from under the wing. Smoke had also started to enter the cabin in the vicinity of the wing root. The pilot subsequently reported that he had selected the master switch on the air conditioning control panel to the ‘vent’ position, and that he had opened the left direct vision window in an attempt to eliminate smoke from the cabin. When that did not appear to have any effect he closed the direct vision window. The pilot of another aircraft reported to ATS that Young was clear, but there were fog patches to the north. On arrival at Young, however, the pilot of the Bandeirante was unable to land the aircraft because of fog, and advised ATS that he was proceeding to Cootamundra, 27 NM to the south southwest of Young. The crew of an overflying airliner informed ATS that Cootamundra was clear of fog. ATS confirmed that advice by telephoning an aircraft operator at Cootamundra aerodrome. At 1017 thick smoke entered the cabin and the pilot transmitted a MAYDAY. He reported that the aircraft was 9 NM from Cootamundra, and ATS informed him that the aerodrome was clear of fog. The pilot advised that he was flying in visual conditions and that there was a serious fire on board. No further radio transmissions were heard from the aircraft. At 1021, approximately 25 minutes after first reporting a fire, the pilot made an approach to land on runway 16 at Cootamundra. He reported that when he selected the landing gear down on late final there was no indication that the gear had extended. The pilot reported that he did not have sufficient time to extend the gear manually using the emergency procedure because he was anxious to get the aircraft on the ground as quickly as possible. Unaware that the right main landing gear had extended the pilot advised the passengers to prepare for a ‘belly’ landing. He lowered full flap, selected the propeller levers to the feathered position and the condition levers to fuel cut-off. The aircraft landed with only the right main landing gear extended. The right main wheel touched down about 260 m beyond the runway threshold, about one metre from the right edge of the runway. During the landing roll the aircraft settled on the nose and the left engine nacelle and skidded for approximately 450 m before veering left off the bitumen. The soft grass surface swung the aircraft sharply left, and it came to a stop on the grass flight strip east of the runway, almost on a reciprocal heading. The pilot and passengers were uninjured, and vacated the aircraft through the cabin door and left overwing emergency exit. Personnel from a maintenance organisation at the aerodrome extinguished the fire in the right engine nacelle using portable fire extinguishers.
Probable cause:
Significant factors:
1. Vibration from the worn armature shaft of the right starter generator resulted in a fractured fuel return line.
2. The armature shaft of the right engine starter generator failed in-flight.
3. Sparks or frictional heat generated by the failed starter generator ignited the combustible fuel/air mixture in the right engine accessory compartment.
4. Items on the engine fire emergency checklist were not completed, and the fire was not suppressed.
5. The operator’s CASA approved emergency checklist did not contain smoke evacuation procedures.
6. The pilot did not attempt to extend the landing gear using the emergency gear extension when he did not to get a positive indication that the gear was down and locked.
7. The aircraft landed on the right main landing gear and slid to a stop on the right main gear, left engine nacelle and nose.
Final Report:

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

Date & Time: Jun 14, 2001 at 1145 LT
Type of aircraft:
Operator:
Registration:
ZK-TMO
Flight Phase:
Survivors:
No
MSN:
012
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7300
Captain / Total hours on type:
261.00
Aircraft flight hours:
5466
Aircraft flight cycles:
65887
Circumstances:
On 13 June 2001, Cresco ZK-TMO arrived at Te Aroha Station, 25 km west of Gisborne, to carry out topdressing of that property. Before operations started, the property owner briefed the pilot, and two observation flights over the areas to be sown were made. The owner also cautioned the pilot against turning left after take-off from the airstrip. Spreading commenced at 1600 hours, and 14 flights with 1800 kg loads were completed that day. The loader driver reported that no difficulties were experienced during those operations. Spreading recommenced at 0720 hours on 14 June 2001, again with 1800 kg loads, in an area to the left (east) of the airstrip. On the third flight after a refuel later in the morning, the loader driver noticed that the pilot made a partial load jettison after take-off; this resulted in a reduced duration of that sortie. However, on return, the pilot did not indicate to the loader driver that he required a reduced load. About 1145 hours, the aircraft was reloaded and commenced take-off. The loader driver watched about half the take-off roll, then continued preparing for the next load. He did not sight the aircraft again before a pall of black smoke attracted his attention. After making a radio call to the aircraft and hearing no response, the loader driver ran towards the smoke, which was to the left of and below the elevated strip. On reaching the site he found the aircraft inverted in a small stream and burning fiercely. The loader driver could see the pilot inside the aircraft but he and the property owner were unable to reach him because of the intense heat of the fire. The accident occurred in daylight, at approximately 1145 hours NZST, at Te Aroha Station; latitude S 38° 38.0' longitude E 177° 41.8', at an elevation of approximately 770 feet.
Probable cause:
The following findings were identified:
- The pilot was appropriately licensed, rated and fit for the flights being undertaken.
- The aircraft had a valid airworthiness certificate and had been maintained in accordance with current requirements.
- No pre-accident defect was found with the aircraft.
- The pilot had turned left after take-off from the strip, against the advice of the property owner.
- The advice was given in light of a previous accident in virtually identical circumstances.
- There was insufficient space available after take-off for the aeroplane to accelerate to a speed at which the bank angle necessary to clear the terrain could be sustained in level flight or a climb.
- The accident was not survivable.
Final Report:

Crash of a Cessna 208 Caravan I in Nagambie: 1 killed

Date & Time: Apr 29, 2001 at 1312 LT
Type of aircraft:
Operator:
Registration:
VH-MMV
Flight Phase:
Survivors:
Yes
Schedule:
Nagambie - Nagambie
MSN:
208-0003
YOM:
1985
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4000
Captain / Total hours on type:
700.00
Aircraft flight hours:
8576
Circumstances:
Four parachutists were practising as a team for a skydiving competition. They had completed seven parachute descents prior to the accident flight. Each descent had been video recorded by a cameraman using a helmet-mounted camera. The parachutists used a Cessna Aircraft Company Caravan aircraft. That aircraft was climbed to 14,000 ft with the team of four parachutists, their cameraman, six other parachutists and the pilot. At the drop altitude, the team members carried out their ‘pin check’ in which each parachutist’s equipment was checked to ensure that the release pins for the main and reserve parachutes were correctly positioned. Approaching overhead the drop zone, a roller blind, which covered the exit doorway on the left side of the aircraft, and minimised windblast during the climb, was raised. The cameraman positioned himself on the step outside and to the rear of the exit doorway. The first three members of the team positioned themselves in the exit doorway. The team member nearest to the front of the aircraft faced out and the next two members faced into the aircraft. The team member in the middle grasped the jumpsuits of the adjacent parachutists. The fourth member was inside the aircraft facing the exit. As the team exited the aircraft, the middle parachutist’s reserve parachute’s pilot chute deployed. Due to the bent over position of that parachutist, the action of the ejector spring in the pilot chute pushed the chute upwards and over the horizontal stabiliser of the aircraft, pulling the reserve canopy with it. The parachutist passed below the horizontal stabiliser resulting in the reserve parachute risers and lines tangling around the left elevator and horizontal stabiliser. Eleven seconds later, the empennage separated from the aircraft and the left elevator and the parachutist separated from the empennage. The parachutist descended to the ground with the reserve and main parachutes entangled and landed 800 metres west of the drop zone landing strip. A short section of the elevator was tangled in the parachute lines. The parachutist’s rate of descent was estimated to be 3.6 times greater than that for an average parachutist under canopy. Immediately after the empennage separated, the aircraft entered a steep, nose-down spiral descent. The pilot instructed the remaining parachutists to abandon the aircraft. The last one left the aircraft before it descended through 9,000 ft. The pilot transmitted a mayday call, shutdown the engine and left his seat. On reaching the rear of the cabin, he found that the roller blind had closed, preventing him from leaving the aircraft. After several attempts, the pilot raised the blind sufficiently to allow him to exit the aircraft, and at an altitude of approximately 1,000 ft above ground level, he deployed his parachute and landed safely. The aircraft, minus the empennage, descended almost vertically and crashed on the drop zone landing strip. It was destroyed by impact forces and the post-impact fire. The empennage, in several pieces, landed 600 metres west of the landing strip. A Country Fire Authority fire vehicle arrived at the accident site within two minutes of the accident and extinguished the fire. The parachutist that had been entangled was fatally injured. The injuries sustained when entangled on the horizontal stabiliser made the parachutist incapable of operating the main parachute. The other parachutists and the pilot were uninjured.
Probable cause:
The following factors were identified:
- The parachutist’s reserve parachute deployed prematurely, probably as a result of the parachute container coming into contact with the aircraft doorframe/handrail.
- The reserve parachute risers and lines tangled around the horizontal stabiliser and elevator.
- The reserve canopy partially filled, applying to the aircraft empennage a load that exceeded its design limits.
- The empennage separated from the aircraft and the elevator separated from the empennage, releasing the parachutist and sending the aircraft out of control.
Final Report:

Crash of a Rockwell Shrike Commander 500S on Thornton Peak: 4 killed

Date & Time: Apr 10, 2001 at 0725 LT
Operator:
Registration:
VH-UJB
Flight Phase:
Survivors:
No
Site:
Schedule:
Cairns - Hicks Island
MSN:
500-3152
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
9680
Captain / Total hours on type:
2402.00
Circumstances:
The aircraft departed Cairns airport at 0707 Eastern Standard Time (EST) on a charter flight to Hicks Island. The aircraft was being operated under the Instrument Flight Rules (IFR) and the expected flight time was 2 hours. Shortly after takeoff the pilot requested an amended altitude of 4,000 ft. He indicated that he was able to continue flight with visual reference to the ground or water. Air Traffic Services (ATS) issued the amended altitude as requested. The IFR Lowest Safe Altitude for the initial route sector to be flown was 6,000 ft Above Mean Sea Level (AMSL). Data recorded by ATS indicated that approximately 13 minutes after departure, the aircraft disappeared from radar at a position 46NM north of Cairns. At the last known radar position the aircraft was cruising at a ground speed of 180 kts and at an altitude of 4,000 ft AMSL. An extensive search located the wreckage the following afternoon at a location consistent with the last known radar position, on the north-western side of Thornton Peak at an altitude of approximately 4,000 ft (1219 metres) AMSL. The aircraft was destroyed by impact forces and post-impact fire. The pilot and three passengers received fatal injuries. Thornton Peak is the third highest mountain in Queensland and is marked on topographic maps as 4,507 ft (1,374 metres) in elevation. Local residents reported that the mountain was covered by cloud and swept by strong winds for most of the year. The aircraft had been observed by witnesses approximately two minutes prior to impact cruising at high speed, on a constant north-westerly heading, in a wings level attitude and with flaps and landing gear retracted. They stated that the engines appeared to sound normal.
Probable cause:
Radar data recorded by Air Traffic Services and witness reports indicated that the aircraft was flying straight and level and maintaining a constant airspeed. Therefore, it is unlikely that the aircraft was experiencing any instrumentation or engine problems. Why the pilot continued flight into marginal weather conditions at an altitude that was insufficient to ensure terrain clearance, could not be established. The aircraft was flown at an altitude that was insufficient to ensure terrain clearance.
Final Report:

Crash of a Boeing 727-223F in Kolonia

Date & Time: Mar 11, 2001 at 1737 LT
Type of aircraft:
Operator:
Registration:
N701NE
Flight Type:
Survivors:
Yes
Schedule:
Majuro - Kolonia
MSN:
22459
YOM:
1981
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Kolonia Airport (Pohnpei Island), the aircraft was too low. It struck the ground just short of runway threshold, causing the right main gear to be torn off and the left main gear to collapse. The aircraft slid on its belly for few dozen metres before coming to rest on the runway. All three crew members escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Fletcher FU-24-950M in Raglan

Date & Time: Dec 15, 2000 at 0640 LT
Type of aircraft:
Operator:
Registration:
ZK-BHL
Flight Phase:
Survivors:
Yes
Schedule:
Raglan - Raglan
MSN:
14
YOM:
1955
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot, sole on board, was engaged in a local crop spraying mission. During the takeoff roll, the aircraft encountered difficulties to gain speed. The pilot suspected problems with the parking brake and after liftoff, the aircraft lost height and crashed to the left of the departure area. The pilot escaped uninjured while the aircraft was damaged beyond repair.