Crash of a De Havilland DHC-6 Twin Otter 200 near Selbang: 28 killed

Date & Time: Dec 17, 1994 at 1320 LT
Operator:
Registration:
P2-MFS
Flight Phase:
Survivors:
No
Site:
Schedule:
Tabubil - Selbang
MSN:
187
YOM:
1968
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
28
Circumstances:
The twin engine aircraft departed Tabubil and a regular schedule flight to Selbang, carrying 26 passengers and two pilots. After passing over Olsobip, the crew encountered poor visibility due to clouds. While flying at an altitude of 6,400 feet in clouds, the aircraft struck the slope of a mountain located about 9 km south of Selbang. The aircraft was destroyed and all 28 occupants were killed. At the time of the accident, the cloud layer was reported from 4,000 to 10,000 feet.
Probable cause:
Controlled flight into terrain.

Crash of a Britten-Norman BN-2A-20 Islander near Tabubil: 7 killed

Date & Time: Nov 22, 1994 at 1140 LT
Type of aircraft:
Operator:
Registration:
P2-SWC
Flight Phase:
Survivors:
No
Site:
Schedule:
Tabubil – Selbang – Bolobip
MSN:
835
YOM:
1977
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
While cruising in poor weather conditions, the twin engine aircraft struck the slope of a mountain located 54 km southeast of Tabubil. The wreckage was found few hours later and all seven occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of a Rockwell Grand Commander 680F near Cloncurry: 2 killed

Date & Time: Nov 9, 1994 at 1015 LT
Operator:
Registration:
VH-SPP
Flight Phase:
Survivors:
No
Schedule:
Cloncurry - Cloncurry
MSN:
680-1128-74
YOM:
1961
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
11400
Captain / Total hours on type:
710.00
Aircraft flight hours:
7546
Circumstances:
The aircraft was engaged in aero-magnetic survey operations in an area which extended from approximately 40–130 km south of Cloncurry. The task involved flying a series of north-south tie lines spaced 2 km apart at a height above ground of 80 m and a speed of 140 kts. At this speed, each tie line occupied about 20 minutes of flight time. The flight was planned to depart Cloncurry at 0700–0730 EST and was to return by 1230 to prepare data collected during the flight for transfer to the company’s head office. An employee of the operating company saw the crew (pilot and equipment operator) preparing to depart the motel for the airport at about 0500. No person has been found who saw the crew at the aerodrome or who saw or heard the aircraft depart. At about 1000, three witnesses at a mining site in the southern section of the survey area saw a twin-engine aircraft at low level heading in a northerly direction. One of these witnesses, about 1.5 hours later, saw what he believed was the same aircraft flying in an easterly direction about 1 km from his position. Between 1000 and 1030, two witnesses at a mine site some 9 km north of the survey area (and about 5 km west of the accident site) heard an aircraft flying in a north-south direction, apparently at low level. On becoming aware that the aircraft had not returned to Cloncurry by 1230, a company employee at Cloncurry initiated various checks at Cloncurry and other aerodromes in the area, with Brisbane Flight Service, and with the company’s head office later in the afternoon. At about 2030, the employee advised the company chief pilot that the aircraft was overdue. The chief pilot contacted the Civil Aviation Authority Search and Rescue organisation at about 2045 and search-and-rescue action was initiated. The burnt-out wreckage of the aircraft was found early the following morning approximately 9 km north of the survey area.
Probable cause:
For reason(s) which could not be conclusively established, the pilot shut off the fuel supply to the left engine and feathered the left propeller. For reason(s) which could not be conclusively established, the pilot lost control of the aircraft.
Final Report:

Crash of a Fletcher FU-24-950 in Kaikohe: 1 killed

Date & Time: Nov 5, 1994 at 0715 LT
Type of aircraft:
Registration:
ZK-EFO
Flight Phase:
Survivors:
No
Schedule:
Kaikohe - Kaikohe
MSN:
218
YOM:
1976
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
764
Captain / Total hours on type:
330.00
Circumstances:
The pilot, sole on board, was engaged in a spraying mission in Kaikohe. The first sowing operation was completed shortly after 0700LT. While flying at low height in good weather conditions, the aircraft banked left to an angle of 45° then nosed down to 30° and crashed 500 metres from the Kaikohe Aerodrome. The aircraft was destroyed and the pilot was killed.
Probable cause:
The position of the turn towards the higher ground may have deprived the pilot of a visual horizon causing him to fly too slowly and the plane to stall and spin. No technical anomalies were found on the aircraft.
Final Report:

Crash of a Mitsubishi MU-2B-60 Marquise off Papeete: 5 killed

Date & Time: May 27, 1994 at 2354 LT
Type of aircraft:
Registration:
F-GDHV
Flight Type:
Survivors:
No
Schedule:
Rarotonga - Papeete
MSN:
779
YOM:
1980
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The aircraft was completing an ambulance flight from Rarotonga (Cook Islands) to Tahiti, carrying to Australian patients, two doctors and one pilot. On final approach to Papeete-Faaa Airport runway 04 by night, the twin engine aircraft descended too low and crashed in the sea about 6,4 km short of runway. The pilot did not send any distress call prior to impact and the aircraft struck the water surface in a flat attitude. All five occupants were killed. For unknown reasons, the pilot failed to realize his altitude was insufficient on short final. The lack of visibility and visual references were considered as contributing factors.

Crash of a Douglas C-47A-20-DK off Sydney

Date & Time: Apr 24, 1994 at 0910 LT
Registration:
VH-EDC
Flight Phase:
Survivors:
Yes
Schedule:
Sydney - Norfolk Island - Lord Howe Island
MSN:
12874
YOM:
1944
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9186
Captain / Total hours on type:
927.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
250
Aircraft flight hours:
40195
Circumstances:
This accident involved a DC-3 aircraft which was owned and operated by South Pacific Airmotive Pty Ltd, who were based at Camden, NSW. It was flown on commercial operations under an Air Operators Certificate held by Groupair, who were based at Moorabbin, Vic. The aircraft had been chartered to convey college students and their band equipment from Sydney to Norfolk Island to participate in Anzac Day celebrations on the island. A flight plan, submitted by the pilot in command, indicated that the aircraft was to proceed from Sydney (Kingsford-Smith) Airport to Norfolk Island, with an intermediate landing at Lord Howe Island to refuel. The flight was to be conducted in accordance with IFR procedures, with a departure time from Sydney of 0900. The aircraft, which was carrying 21 passengers, was crewed by two pilots, a supernumerary pilot and a flight attendant. Preparations for departure were completed shortly before 0900, and the aircraft was cleared to taxi for runway 16 via taxiway Bravo Three. The pilot in command occupied the left control position. The co-pilot was the handling pilot for the departure. The aircraft was cleared for takeoff at 0907:53. The crew subsequently reported to the investigation team that all engine indications were normal during the take-off roll and that the aircraft was flown off the runway at 81 kts. During the initial climb, at approximately 200 ft, with flaps up and the landing gear retracting, the crew heard a series of popping sounds above the engine noise. Almost immediately, the aircraft began to yaw left and at 0909:04 the pilot in command advised the TWR that the aircraft had a problem. The co-pilot determined that the left engine was malfunctioning. The crew subsequently recalled that the aircraft speed at this time had increased to at least 100 kts. The pilot in command, having verified that the left engine was malfunctioning, closed the left throttle and initiated propeller feathering action. During this period, full power (48 inches Hg and 2,700 RPM) was maintained on the right engine. However, the airspeed began to decay. The handling pilot reported that he had attempted to maintain 81 KIAS but was unable to do so. The aircraft diverged to the left of the runway centreline. The co-pilot and the supernumerary pilot subsequently reported that almost full right aileron had been used to control the aircraft. They could not recall the skid-ball indication. The copilot reported that he had full right rudder or near full right rudder applied. When he first became aware of the engine malfunction, the pilot in command assessed that, although a landing back on the runway may have been possible, the aircraft was capable of climbing safely on one engine. However, when he determined that the aircraft was not climbing, and that the airspeed had reduced below 81 kts, the pilot in command took control, and at 0909:38 advised the TWR that he was ditching the aircraft. He manoeuvred the aircraft as close as possible to the southern end of the partially constructed runway 16L. The aircraft was ditched approximately 46 seconds after the pilot in command first advised the TWR of the problem. The four crew and 21 passengers successfully evacuated the aircraft before it sank. They were taken on board pleasure craft and transferred to shore. After initial assessment, they were transported to various hospitals. All were discharged by 1430 that afternoon, with the exception of the flight attendant, who had suffered serious injuries.
Probable cause:
The following factors were considered significant in the accident sequence.
1. Compliance with the correct performance charts would have precluded the flight.
2. Clear and unambiguous presentation of CAA EROPs documentation should have precluded the flight.
3. The aircraft weight at takeoff exceeded the MTOW, the extent of which was unknown to the crew.
4. An engine malfunction and resultant loss of performance occurred soon after takeoff.
5. The operations manual take-off safety speed used by the crew was inappropriate for the overloaded condition of the aircraft.
6. The available single-engine aircraft performance was degraded when the co-pilot mishandled the aircraft controls.
7. The pilot in command delayed taking over control of the aircraft until the only remaining option was to conduct a controlled ditching.
8. There were organisational deficiencies in the management and operation of the DC-3 involving both Groupair and SPA.
9. There were organisational deficiencies in the safety regulation of both Groupair and SPA by the CAA district offices at Moorabbin and Bankstown.
10. There were organisational deficiencies relating to safety regulation of EROPS by the CAA.
Final Report:

Crash of a PAC Fletcher FU-24-950M in Ngaruawahia: 1 killed

Date & Time: Mar 30, 1994 at 1200 LT
Type of aircraft:
Operator:
Registration:
ZK-DZB
Flight Phase:
Survivors:
No
Schedule:
Ngaruawahia - Ngaruawahia
MSN:
202
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
338
Captain / Total hours on type:
5.00
Circumstances:
The day's operation commenced at about 06:30 with the student flying and the instructor operating the loader.The intention was to fly for two hours when a break would be taken in order to rest the trainee pilot, check the fuel state, and review the sowing operation so far. Shortly before 08:20 the trainee took off on what was about the twentieth sowing flight of the day. The Fletcher was loaded with 19 hundredweight (cwt) or 965 kg of lime in the hopper. The usual pattern was flown and the aircraft was positioned for a sowing run along a ridge face at about 100 feet AGL. However, on this run no lime was dropped and at about the usual commencement point for sowing the aircraft made a sharp turn to the left and flew out over level ground, away from the ridge. After turning through about 120 degrees the plane pitched nose-down suddenly and dived almost vertically into the ground. It bounced over a hedge and came to rest 10 metres beyond the initial point of impact. This was not a survivable crash. Despite the spillage of considerable fuel no fire broke out. The flying weather was calm with good visibility. Weather was not a factor in this accident.
Probable cause:
No firm reason for the pilot to abandon his sowing run and make a steep turn away from the ridge could be found. It was noted that the change of heading took the plane on a course towards the sun and also a 100- feet-tall tree that may have caused the pilot to take abrupt avoiding action, causing the plane to stall and fall into an incipient spin from which control could not be regained owing to the limited height available.
Final Report:

Crash of a Britten-Norman BN-2A-21 Islander in Weipa: 6 killed

Date & Time: Mar 21, 1994 at 1754 LT
Type of aircraft:
Registration:
VH-JUU
Flight Phase:
Survivors:
No
Schedule:
Weipa - Aurukun
MSN:
632
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
321
Captain / Total hours on type:
6.00
Circumstances:
On the day before the accident, the aircraft flew from Aurukun to Weipa with the chief pilot occupying the left pilot seat and the pilot involved in the accident occupying the right pilot seat. At Weipa the chief pilot left the aircraft, instructing the other pilot to fly some practice circuits before returning the aircraft to Aurukun. Before commencing the circuits and the return flight to Aurukun, the aircraft's two main tanks each contained 100 L of fuel and the two wing tip tanks each contained about 90 L of fuel. On the day of the accident the pilot added 200 L of fuel at Aurukun to the aircraft's tanks and then flew the aircraft and the passengers to Weipa. About 50 minutes before sunset, the aircraft taxied for departure from runway 30 for the 25-minute return flight to Aurukun. When the aircraft was about 300 ft above ground level after takeoff, a witness reported that all engine sounds stopped and that the aircraft attitude changed from a nose-high climb to a more level attitude. A short time later, the noise of engine power surging was heard. The aircraft rolled left and entered a spiral descent. It struck level ground some 350 m beyond the departure end of runway 30 and 175 m to the left of the extended centreline. All six occupants were killed.
Probable cause:
Significant factors:
- The pilot mismanaged the aircraft fuel system.
- Both engines suffered a total power loss due to fuel starvation.
- The right engine regained power probably as a result of a change in aircraft attitude.
- The pilot lost control of the aircraft.
- Recovery was not possible in the height available.
Final Report:

Crash of a Swearingen SA226AT Merlin IVA in Tamworth: 1 killed

Date & Time: Mar 9, 1994 at 1734 LT
Operator:
Registration:
VH-SWP
Flight Type:
Survivors:
No
Schedule:
Inverell – Glen Innes – Armidale – Tamworth – Sydney
MSN:
AT-033
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2782
Captain / Total hours on type:
335.00
Circumstances:
VH-SWP was operating on a standard company flight plan for the route Bankstown-Tamworth-Armidale-Glen Innes-Inverell and return, and the flight plan indicated the flight would be conducted in accordance with IFR procedures. The classification of the flight was shown as non-scheduled commercial air transport although the aircraft was operating to a company schedule, and departure and flight times for each route segment were indicated on the flight plan. The aircraft departed Bankstown at about 0640 and proceeded as planned to Inverell where the pilot rested until his departure that afternoon for the return journey. The schedule required an Armidale departure at 1721. At 1723 the pilot reported to Sydney Flight Service that he was departing Armidale for Tamworth. The planned time for the flight was 17 minutes. Although the flight-planned altitude for this sector was 6,000 ft, the pilot was unable to climb immediately because a slower aircraft, which had departed Armidale for Tamworth two minutes earlier, was climbing to that altitude. In addition, there was opposite direction traffic at 7,000 ft. The next most suitable altitude was 8,000 ft, but separation from the other two aircraft, which were also IFR, had to be established by the pilot before further climb was possible. The published IFR lowest safe altitude for the route was 5,400 ft. The pilot subsequently elected to remain at 4,500 ft in visual meteorological conditions (VMC) and at 1727 requested an airways clearance from Tamworth Tower. A clearance was issued by ATC to the pilot to track direct to Tamworth at 4,500 ft visually. At about 1732 the pilot requested a descent clearance. He was cleared to make a visual approach with a clearance limit of 5 NM by distance measuring equipment (DME) from Tamworth, and was requested to report at 8 DME from Tamworth. The pilot acknowledged the instructions and reported leaving 4,500 ft on descent. Transmissions from ATC to the pilot less than two minutes later were not answered. The aircraft was not being monitored on radar by ATC, nor was this a requirement. At about 1740, reports were received by the police and ATC of an explosion and possible aircraft accident near the mountain range 8 NM north-east of Tamworth Airport. The aircraft wreckage was discovered at about 2115 by searchers on the mountain range.Soon after the aircraft was reported missing, a search aircraft pilot, who had extensive local flying experience, reported to ATC that the top of the range (where the accident occurred) was obscured by cloud, and that there was very low cloud in the valley nearby.
Probable cause:
The following findings were reported:
- The pilot was making a visual approach in weather conditions unsuitable for such an approach.
- The pilot had not flown this route before.
- The aircraft was flown below the lowest safe altitude in conditions of poor visibility.

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

Date & Time: Jan 14, 1994 at 0114 LT
Registration:
VH-BSS
Flight Type:
Survivors:
No
Schedule:
Canberra - Sydney
MSN:
690-11044
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1800
Captain / Total hours on type:
50.00
Aircraft flight hours:
7975
Circumstances:
On 14 January 1994 at 0114, Aero Commander 690 aircraft VH-BSS struck the sea while being radar vectored to intercept the Instrument Landing System approach to runway 34 at Sydney (Kingsford-Smith) Airport, NSW. The last recorded position of the aircraft was about 10 miles to the south-east of the airport. At the time of the accident the aircraft was being operated as a cargo charter flight from Canberra to Sydney in accordance with the Instrument Flight Rules. The body of the pilot who was the sole occupant of the aircraft was never recovered. Although wreckage identified as part of the aircraft was located on the seabed shortly after the accident, salvage action was not initially undertaken. This decision was taken after consideration of the known circumstances of the occurrence and of the costs of salvage versus the potential safety benefit that might be gained from examination of the wreckage. About 18 months after the accident, the wing and tail sections of the aircraft were recovered from the sea by fishermen. As a result, a detailed examination of that wreckage was carried out to assess the validity of the Bureau’s original analysis that the airworthiness of the aircraft was unlikely to have been a factor in this accident. No evidence was found of any defect which may have affected the normal operation of the aircraft. The aircraft descended below the altitude it had been cleared to by air traffic control. From the evidence available it was determined that the circumstances of this accident were consistent with controlled flight into the sea.
Probable cause:
Findings
1. The pilot held a valid pilot licence, endorsed for Aero Commander 690 aircraft.
2. The pilot held a valid multi-engine command instrument rating.
3. There was no evidence found to indicate that the performance of the pilot was adversely affected by any physiological or psychological condition.
4. The aircraft was airworthy for the intended flight, despite the existence of minor anomalies in maintenance and serviceability of aircraft systems.
5. The aircraft carried fuel sufficient for the flight.
6. The weight and balance of the aircraft were estimated to have been within the normal limits.
7. Recorded radio communications relevant to the operation of the aircraft were normal.
8. Relevant ground-based aids to navigation were serviceable.
9. At the time of impact the aircraft was capable of normal flight.
10. The aircraft was fitted with an altitude alerting system.
11. The aircraft was not fitted with a ground proximity warning system.
12. The aircraft was equipped with a transponder which provided aircraft altitude information to be displayed on Air Traffic Control radar equipment.
3.2 Significant factors
1. The pilot was relatively inexperienced in single-pilot Instrument Flight Rules operations on the type of aircraft being flown.
2. The aircraft was being descended over the sea in dark-night conditions.
3. The workload of the pilot was significantly increased by his adoption of a steep descent profile at high speed, during a phase of flight which required multiple tasks to be completed in a limited time prior to landing. Radio communications with another company aircraft during that critical phase of flight added to that workload.
4. The pilot probably lost awareness of the vertical position of the aircraft as a result of distraction by other tasks.
5. The aircraft was inadvertently descended below the altitude authorized by Air Traffic Control.
6. The secondary surveillance radar system in operation at the time provided an aircraft altitude readout which was only updated on every sixth sweep of the radar display.
7. The approach controller did not notice a gross change of aircraft altitude shortly after a normal radio communication with the pilot.
Final Report: