Crash of a Rockwell Shrike Commander 500S in Horn Island: 1 killed

Date & Time: Dec 12, 1995 at 0918 LT
Operator:
Registration:
VH-UJP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Horn Island - Horn Island
MSN:
500-3074
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
11740
Captain / Total hours on type:
119.00
Circumstances:
At approximately 0910 EST, the aircraft took off from runway 32 at Horn Island and commenced a normal climb. Shortly after, it adopted a nose-high attitude and commenced a wingover type manoeuvre to the right. Witnesses described the aircraft as being in a nose-low attitude, and at a height of approximately 600 ft to 700 ft above ground level after the completion of this manoeuvre. It then abruptly adopted a level attitude and rapidly entered a spin to the left. Witnesses on the ground reported that at approximately the same time as the aircraft entered the spin, engine power became asymmetric, with the right engine continuing to deliver considerable power. The aircraft continued to descend in a fully developed flat spin, with no observed signs of an attempt to recover. The impact was heard shortly after the aircraft descended behind vegetation to the north-west of the aerodrome. The accident was reported to Flight Service by radio at 0918. The wreckage was located on a beach approximately 2 km to the north-west of the aerodrome. The aircraft was destroyed by impact forces and the pilot sustained fatal injuries.
Probable cause:
The following findings were reported:
1. The pilot held a valid pilot licence and medical certificate.
2. The pilot was endorsed on the aircraft type.
3. The aircraft entered a flat spin to the left with no reported signs of an attempt to recover.
4. The aircraft struck the ground whilst established in a flat left spin.
5. The right engine was producing considerable power prior to impact.
6. Indications were that the left engine was producing little or no power. Its propeller was in the feathered position prior to impact.
7. No evidence was found to indicate a malfunction or pre-existing defect with the aircraft or its systems which may have affected normal operation during this flight.
8. No evidence was found to indicate pilot incapacitation as the result of a medical condition or the presence of alcohol or drugs.
9. The pilot's behaviour on the morning of the accident was not consistent with what was generally accepted to be a thorough and professional attitude to aviation.
Final Report:

Crash of a Partenavia P.68B in Tangalooma

Date & Time: Nov 22, 1995 at 2110 LT
Type of aircraft:
Registration:
VH-TLQ
Flight Phase:
Survivors:
Yes
Schedule:
Tangalooma – Coolangatta
MSN:
33
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
905
Captain / Total hours on type:
57.00
Circumstances:
The aircraft was the second to take off in a stream of six on a night flight from the Tangalooma Resort strip to Coolangatta aerodrome. Shortly after takeoff it struck the ground, nosed over and was consumed by a fuel-fed fire. The take-off run appeared normal but the initial climb was shallow according to the witnesses, some of whom were pilots waiting their turn to take off. At about 150 ft above ground level the aircraft entered a descent which continued until ground impact, 164 m beyond the departure end of the strip. The nose gear collapsed at impact but the aircraft remained upright and skidded along the ground on its main gear and front fuselage. It traversed a low sand dune, fell 10 ft to the beach and overturned. The aircraft came to rest 112 m beyond the first ground contact. All four passengers were able to evacuate the aircraft which had started to burn. The pilot was rescued by her passengers.
Probable cause:
The following factors were reported:
1. The takeoff direction was dark and had no visible horizon.
2. The elevator trim was not set for takeoff.
3. The elevator load on takeoff was high.
4. The pilot did not monitor the aircraft attitude after lift-off.
5. The flap was retracted in one movement, increasing the elevator load.
6. The pilot may have been affected by somatogravic illusion to the extent that she thought the climb attitude was adequate.
Final Report:

Crash of a Fletcher FU-24-954 in Rongoio Station: 1 killed

Date & Time: Nov 1, 1995 at 1020 LT
Type of aircraft:
Operator:
Registration:
ZK-EUG
Flight Phase:
Survivors:
No
Schedule:
Rongoio Station - Rongoio Station
MSN:
284
YOM:
1982
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10000
Captain / Total hours on type:
8500.00
Circumstances:
The pilot was completing spraying mission in the region of Rongoio Station, about 18 nm north of Wairoa. In flight, control was lost and the aircraft crashed, bursting into flames. The pilot, sole on board, was killed.
Probable cause:
The following findings were reported:
- The pilot suffered an acute myocardial infarction while in flight,
- The effects of the myocardial infarction probably led initially to loss of situational awareness and loss of control of the aircraft,
- The pilot may have realised at a late stage that a collision with the ground was imminent, but was unable to recover from the situation in time to avoid it.
Final Report:

Crash of a Swearingen SA227AC Metro III in Tamworth: 2 killed

Date & Time: Sep 16, 1995 at 1957 LT
Type of aircraft:
Operator:
Registration:
VH-NEJ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tamworth - Tamworth
MSN:
AC-629B
YOM:
1985
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4132
Captain / Total hours on type:
1393.00
Copilot / Total flying hours:
1317
Copilot / Total hours on type:
1
Aircraft flight hours:
15105
Circumstances:
Two company pilots were undergoing first officer Metro III type-conversion flying training. Both had completed Metro III ground school training during the week before the accident. A company check-and-training pilot was to conduct the type conversions. This was his first duty period after 2 weeks leave. Before commencing leave, he had discussed the training with the chief pilot. This discussion concerned the general requirements for a co-pilot conversion course compared to a command pilot course but did not address specific sequences or techniques. The three pilots met at the airport at about 1530 EST on 16 September 1995. During the next 2 hours and 30 minutes approximately, the check-and-training pilot instructed the trainees in daily and pre-flight inspections, emergency equipment and procedures, and cockpit procedures and drills (including the actions to be completed in the event of an engine failure), as they related to the aircraft type. The briefing did not include detailed discussion of aircraft handling following engine failure on takeoff. The group began a meal break at 1800 and returned to the aircraft at about 1830 to begin the flying exercise. The check-and-training pilot was pilot in command for the flight and occupied the left cockpit seat. One trainee occupied the right (co-pilot) cockpit seat while the other probably occupied the front row passenger seat on the left side. This person had the use of a set of head-phones to listen to cockpit talk and radio calls. The aircraft departed Tamworth at 1852, some 40 minutes after last light. Witnesses described the night as very dark, with no moon. Under these conditions, the Tamworth city lighting, which extended to the east from about 2 km beyond the end of runway 12, was the only significant visual feature in the area. The co-pilot performed the takeoff, his first in the Metro III. For about the next 30 minutes, he completed various aircraft handling exercises including climbing, descending, turning (including steep turns), and engine handling. No asymmetric flight exercises were conducted. The check-and-training pilot then talked the co-pilot through an ILS approach to runway 30R with an overshoot and landing on runway 12L. The landing time was 1940. The aircraft had functioned normally throughout the flight. After clearing the runway, the aircraft held on a taxiway for 6 minutes, with engines running. During this period, the crew discussed the next flight which was to be flown by the same co-pilot. The check-and-training pilot stated that he was going to give the co-pilot a V1 cut. The co-pilot objected and then questioned the legality of night V1 cuts. The check-and-training pilot replied that the procedure was now legal because the company operations manual had been changed. The co-pilot made a further objection. The check-and-training pilot then said that they would continue for a Tamworth runway 30R VOR/DME approach and asked the co-pilot to brief him on this approach. The crew discussed the approach and the check-and-training pilot then requested taxi clearance. The aircraft was subsequently cleared to operate within a 15-NM radius of Tamworth below 5,000 ft. The crew then briefed for the runway 12L VOR/DME approach. The plan was to reconfigure the aircraft for normal two-engine operations after the V1 cut and then complete the approach. The crew completed the after-start checks, the taxi checks, and then the pre-take-off checks. The checks included the co-pilot calling for one-quarter flap and the check-and-training pilot responding that one-quarter flap had been selected. The crew briefed the take-off speeds as V1 = 100 kts, VR = 102 kts, V2 = 109 kts, and Vyse = 125 kts for the aircraft weight of 5,600 kg. Take-off torque was calculated as 88% and watermethanol injection was not required. The aircraft commenced the take-off roll at 1957.05. About 25 seconds after brakes release, the check-and-training pilot called 'V1', and less than 1 second later, 'rotate'. The aircraft became airborne at 1957.32. One second later, the check-and-training pilot reminded the co-pilot that the aircraft attitude should be 'just 10 degrees nose up'. After a further 3 seconds, the check-and-training pilot retarded the left engine power lever to the flight-idle position. Over the next 4 seconds, the recorded magnetic heading of the aircraft changed from 119 degrees to 129 degrees. The co-pilot and then the check-and-training pilot called that a positive rate of climb was indicated and the landing gear was selected up 15 seconds after the aircraft became airborne. The landing gear warning horn began to sound at approximately the same time. After 19 seconds airborne, and again after 30 seconds, the check-and-training pilot reminded the co-pilot to hold V2. Three seconds later, the check-and-training pilot said that the aircraft was descending. The landing gear warning horn ceased about 1 second later. By this time, the aircraft had gradually yawed left from heading 129 degrees, through the runway heading of 121 degrees, to 107 degrees. After being airborne for 35 seconds, the aircraft struck a tree approximately 350 m beyond, and 210 m left of, the upwind end of runway 12L. It then rolled rapidly left, severed power lines and struck other trees before colliding with the ground in an inverted attitude and sliding about 70 m. From the control tower, the aerodrome controller saw the aircraft become airborne. As it passed abeam the tower, the controller directed his attention away from the runway. A short time later, all lighting in the tower and on the airport failed and the controller noticed flames from an area to the north-east of the runway 30 threshold. Within about 30 seconds, when the emergency power supply had come on line, the controller attempted to establish radio contact with the aircraft. When no response was received, he initiated call-out of the emergency services.
Probable cause:
The following factors were reported:
1. There was no enabling legislative authority for AIP (OPS) para. 77.
2. CASA oversight, with respect to the company operations manual and specific guidance concerning night asymmetric operations, was inadequate.
3. The company decided to conduct V1 cuts at night during type-conversion training.
4. The check-and-training pilot was assigned a task for which he did not possess adequate experience, knowledge, or skills.
5. The check-and-training pilot gave the co-pilot a night V1 cut, a task which was inappropriate for the co-pilot's level of experience.
6. The performance of the aircraft during the flight was adversely affected by the period the landing gear remained extended after the simulated engine failure was initiated and by the control inputs of the co-pilot.
7. The check-and-training pilot did not recognise that the V1 cut exercise should be terminated and that he should take control of the aircraft.
Final Report:

Crash of a Britten-Norman BN-2A-21 Islander in Fane

Date & Time: Jul 29, 1995
Type of aircraft:
Registration:
P2-MBM
Survivors:
Yes
MSN:
503
YOM:
1977
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Fane Airport runway 19, the twin engine aircraft lost height, struck the ground few metres short of runway threshold and came to rest upside down. All 12 occupants were injured and the aircraft was written off. Runway 19 is 1,480 metres long and has a 12° slope. Takeoff and landings can be completed in one direction only.

Crash of a Britten-Norman BN-2A-20 Islander in Karimui: 2 killed

Date & Time: Jul 25, 1995
Type of aircraft:
Registration:
P2-TNT
Flight Phase:
Survivors:
No
MSN:
393
YOM:
1974
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Karimui Airfield, while in initial climb, the left engine failed. The aircraft rolled to the left and crashed near the runway end. Both occupants were killed.
Probable cause:
Failure of the left engine shortly after takeoff due to fuel exhaustion. It was reported that the fuel tank connected to the engine was empty at the time of the accident and that the pilot already completed other flights during the day between Karimui and Kundiawa and back without adding fuel.

Crash of a De Havilland DHC-6 Twin Otter 300 off Alotau: 15 killed

Date & Time: Jul 12, 1995 at 0800 LT
Operator:
Registration:
P2-MBI
Flight Phase:
Survivors:
No
Schedule:
Alotau - Wedau
MSN:
275
YOM:
1969
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
15
Circumstances:
Shortly after takeoff from Alotau Airport, while in initial climb, the aircraft caught fire and suffered an explosion. It entered an uncontrolled descent and crashed in shallow water about 2 km offshore. The aircraft was totally destroyed by impact forces and all 15 occupants were killed.
Probable cause:
An investigation conducted by the Australian Transport Safety Bureau (ATSB) revealed that an explosion and fire occurred shortly after takeoff, causing the electrical system to fail. The fire's source probably was the terminal board between the inverters and a control relay. Kerosene carried in passenger luggage in the Twin Otter's aft cargo hold possibly began leaking and was possibly ignited by faulty or age-deteriorated electrical wiring.

Crash of a De Havilland DHC-4A Caribou in Kiunga: 2 killed

Date & Time: Jul 1, 1995
Type of aircraft:
Registration:
P2-VTC
Flight Type:
Survivors:
Yes
Schedule:
Port Moresby – Tabubil
MSN:
13
YOM:
1960
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
While descending to Tabubil Airport on a cargo flight from Port Moresby, the crew encountered poor weather conditions and decided to divert to Kiunga. While approaching Kiunga, the right engine failed, followed shortly later by the left engine. The aircraft lost height, struck trees and crashed 5 km from the airport. One pilot survived while both other occupants were killed. The aircraft was leased to the Vanimo Trading Company.
Probable cause:
Double engine failure for unknown reasons. The assumption of a fuel starvation seems excluded.

Crash of a De Havilland DHC-8-102 in Palmerston North: 4 killed

Date & Time: Jun 9, 1995 at 0925 LT
Operator:
Registration:
ZK-NEY
Survivors:
Yes
Schedule:
Auckland - Palmerston North
MSN:
055
YOM:
1986
Flight number:
AN703
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
7765
Captain / Total hours on type:
273.00
Copilot / Total flying hours:
6460
Copilot / Total hours on type:
341
Aircraft flight hours:
22154
Aircraft flight cycles:
24976
Circumstances:
At 08:17 Ansett New Zealand Flight 703 departed Auckland (AKL) as scheduled bound for Palmerston North (PMR). To the north of Palmerston North the pilots briefed themselves for a VOR/DME approach to runway 07 which was the approach they preferred. Subsequently Air Traffic Control specified the VOR/DME approach for runway 25, due to departing traffic, and the pilots re-briefed for that instrument approach. The IMC involved flying in and out of stratiform cloud, but continuous cloud prevailed during most of the approach. The aircraft was flown accurately to join the 14 nm DME arc and thence turned right and intercepted the final approach track of 250° M to the Palmerston North VOR. During the right turn, to intercept the inbound approach track, the aircraft’s power levers were retarded to 'flight idle' and shortly afterwards the first officer advised the captain ".... 12 DME looking for 4000 (feet)". The final approach track was intercepted at approximately 13 DME and 4700 feet, and the first officer advised Ohakea Control "Ansett 703" was "established inbound". Just prior to 12 miles DME the captain called "Gear down". The first officer asked him to repeat what he had said and then responded "OK selected and on profile, ten - sorry hang on 10 DME we’re looking for four thousand aren’t we so - a fraction low". The captain responded, "Check, and Flap 15". This was not acknowledged but the first officer said, "Actually no, we’re not, ten DME we’re..... (The captain whistled at this point) look at that". The captain had noticed that the right hand main gear had not locked down: "I don’t want that." and the first officer responded, "No, that’s not good is it, so she’s not locked, so Alternate Landing Gear...?" The captain acknowledged, "Alternate extension, you want to grab the QRH?" After the First Officer’s "Yes", the captain continued, "You want to whip through that one, see if we can get it out of the way before it’s too late." The captain then stated, "I’ll keep an eye on the airplane while you’re doing that." The first officer located the appropriate "Landing Gear Malfunction Alternate Gear Extension" checklist in Ansett New Zealand’s Quick Reference Handbook (QRH) and began reading it. He started with the first check on the list but the captain told him to skip through some checks. The first officer responded to this instruction and resumed reading and carrying out the necessary actions. It was the operator’s policy that all items on the QRH checklists be actioned, or proceeded through, as directed by the captain. The first officer started carrying out the checklist. The captain in between advised him to pull the Main Gear Release Handle. Then the GPWS’s audio alarm sounded. Almost five seconds later the aircraft collided with terrain. The Dash 8 collided with the upper slope of a low range of hills.
Probable cause:
The captain not ensuring the aircraft intercepted and maintained the approach profile during the conduct of the non-precision instrument approach, the captain's perseverance with his decision to get the undercarriage lowered without discontinuing the instrument approach, the captain's distraction from the primary task of flying the aircraft safely during the first officer's endeavours to correct an undercarriage malfunction, the first officer not executing a Quick Reference Handbook procedure in the correct sequence, and the shortness of the ground proximity warning system warning.
Final Report:

Crash of a Fletcher FU-24-954 in Lake Grassmere: 1 killed

Date & Time: Jun 7, 1995 at 1100 LT
Type of aircraft:
Operator:
Registration:
ZK-EMU
Flight Phase:
Survivors:
No
Site:
Schedule:
Lake Grassmere - Lake Grassmere
MSN:
274
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:
4930
Captain / Total hours on type:
235.00
Circumstances:
Shortly after takeoff from a field located in Lake Grassmere, while completing the 8th sortie of the morning, the pilot lost control of the airplane that crashed on hilly terrain. The aircraft was destroyed and the pilot was killed.
Probable cause:
Pilot incapacitation was the probable cause of this accident. The incapacitation of this pilot was an unusual event, and could not have been predicted or prevented by any reasonable or effective medical screening process.
Final Report: