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

Date & Time: May 29, 1993 at 1258 LT
Registration:
VH-LIC
Flight Phase:
Survivors:
Yes
Schedule:
Port Augusta – Innamincka – Durham Downs
MSN:
31-7652173
YOM:
1976
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2930
Captain / Total hours on type:
966.00
Circumstances:
The pilot was conducting a scheduled passenger service flight from Port Augusta with a stop at Innamincka. A commercial pilot, travelling as a non-paying passenger, occupied the co-pilot's seat to observe the operation. Two additional passengers were on board the aircraft for the entire flight. After landing at Innamincka, the aircraft was refuelled by the pilot in command and the oil levels of both engines were checked by the observer, who experienced difficulty securing the combination oil filler cap-dipsticks. He asked the pilot for instructions and, although some advice was given, the pilot did not check the security of the dipsticks. Take-off was commenced towards the north into a 10-15 knot wind with a surface temperature of about 20 degrees C. Shortly after lift-off, at the first power reduction, the observer in the co-pilot's seat advised that there was oil seeping back along the cowl from the right side oil filler hatch. The pilot reported that he increased power to both engines but believed there was no response from the right. He began an immediate left turn to complete a circuit and attempted to secure the right engine and feather the propeller. The aircraft then began a roll to the right, the nose dropped and the aircraft impacted the ground. As the aircraft rolled right and the nose dropped, the pilot reported that he had secured the left engine and feathered the propeller. The observer in the co-pilot seat reported hearing a continuous stall warning horn as the right wing began to drop. All occupants, although injured, were able to vacate the aircraft through the main cabin door. The pilot provided assistance to the passengers and then returned to the airport to summon help.
Probable cause:
Examination of the wreckage revealed that the aircraft impacted the ground in a nose down, right wing low attitude while turning right. The landing gear collapsed due to impact forces and the right wing separated. Deceleration and impact forces were severe. The right propeller was found in the fine pitch range with no damage to the uppermost blade and the other two bent backwards. The right engine oil filler cap-dipstick was found to be correctly installed in the oil filler neck. There was a pattern of engine oil over the rear of the engine and inside the cowl originating from the oil filler neck. The left engine was partially torn from its mountings and displaced about 90 degrees to the right. Its propeller was in the fully feathered position. The oil filler cap-dipstick was on the ground adjacent to the engine. An oil spill pattern similar to that on the right engine was evident.
Significant Factors:
- The pilot-in-command reacted inappropriately to a perceived engine problem shortly after take-off.
- Control of the aircraft was lost at a height insufficient to effect a recovery.
Final Report:

Crash of a Britten-Norman BN-2A-27 Islander in Suva: 2 killed

Date & Time: May 11, 1993
Type of aircraft:
Operator:
Registration:
DQ-FEO
Flight Type:
Survivors:
No
Schedule:
Lakeba - Suva
MSN:
9
YOM:
1967
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The twin engine aircraft departed Lakeba Island Airport on a cargo flight to Suva, carrying one passenger, one pilot and a load of fish. On final approach to Suva-Nausori Airport runway 10, the pilot encountered strong winds. On short final, the aircraft was too low and collided with a taxi driving on a road passing about 200 metres short of runway 10 threshold. The aircraft went out of control and crashed, bursting into flames. Both occupants in the plane were killed while both occupants in the taxi were seriously injured.
Probable cause:
The pilot was completing the approach at an insufficient altitude. Strong winds were considered as a contributing factor.

Crash of a Swearingen SA226AC Metro II in Mackay

Date & Time: Apr 14, 1993 at 0525 LT
Type of aircraft:
Operator:
Registration:
VH-UZS
Flight Type:
Survivors:
Yes
Schedule:
Brisbane - Mackay
MSN:
TC-320
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2670
Captain / Total hours on type:
181.00
Circumstances:
The aircraft was operating a freight charter flight, cruising normally at an altitude of 20,000 ft (FL200), when, about 150 km south-east of Mackay, the left engine lost power and could not be restarted. During the subsequent landing on runway 14 at Mackay, the pilot attempted a single engine go-around when he suddenly had the (mistaken) impression that the landing gear was not down. He temporarily lost control of the aircraft but recovered to touch down on the flight strip to the left of the runway, some 500 m before the runway end. During the landing roll, the landing gear collapsed and the aircraft sustained substantial damage.
Probable cause:
The report concludes that the engine power loss was caused by failure of the fuel pump high pressure relief valve. The pilot, believing that the landing gear was still retracted, initiated action to avoid a wheels-up landing. This action was initiated too late in the landing approach for a successful outcome.
Final Report:

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

Date & Time: Jan 23, 1993 at 0923 LT
Type of aircraft:
Operator:
Registration:
P2-ISF
Survivors:
Yes
MSN:
281
YOM:
1971
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Bambu Airstrip (runway 410 metres long), the pilot saw the windsock moving but estimated the wind to be relatively calm. While completing the flare, the aircraft was caught by a sudden updraft and landed too far down the runway. Unable to stop within the remaining distance, it overran and came to rest in bushes. All four occupants escaped uninjured and the aircraft was written off. At the time of the accident, weather conditions were considered as fine with overcast at 8,000 feet and good visibility below clouds. The Bambu runway has a gradient of 9,25% and is very short. Here, the pilot should initiate a go-around procedure as a safe landing was not possible in such conditions.

Crash of a Britten-Norman BN-2A-26 Islander near Alotau: 6 killed

Date & Time: Dec 15, 1992
Type of aircraft:
Operator:
Registration:
P2-MBE
Flight Phase:
Survivors:
No
Site:
Schedule:
Alotau – Bwagaoia
MSN:
194
YOM:
1970
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
After takeoff from Alotau Airport, the pilot followed the published departure procedure for about 17 km when he initiated a turn to the left bound to the northwest, always below clouds. Then, the aircraft entered clouds when, less than two minutes later, it struck the slope of a mountain located some 25 km from Alotau. The aircraft was destroyed and all six occupants were killed.
Probable cause:
Controlled flight into terrain after the pilot was flying under VFR mode in IMC conditions.

Crash of an Embraer EMB-110P1 Bandeirante near Goroka: 11 killed

Date & Time: Apr 14, 1992
Operator:
Registration:
P2-RDS
Survivors:
Yes
Site:
Schedule:
Madang - Goroka
MSN:
110-355
YOM:
1981
Flight number:
GV709
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
While descending to Goroka Airport in marginal weather conditions, the twin engine aircraft struck the slope of a mountain located 16 km from the airport, near Daulo Pass. Four passengers were seriously injured while 11 other occupants were killed.
Probable cause:
For unknown reasons, the crew initiated the descent prematurely, causing the aircraft to descent below the MDA. Lack of visibility was a contributing factor.

Crash of a Fletcher FU24-954 in Coogah: 1 killed

Date & Time: Mar 16, 1992
Type of aircraft:
Operator:
Registration:
VH-EOG
Flight Phase:
Survivors:
No
Site:
MSN:
3
YOM:
1954
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Crashed in unknown circumstances in a hilly terrain while engaged in a superphosphate spraying mission. The pilot, sole on board, was killed.

Crash of a De Havilland DH.114 Heron 2B in Suva

Date & Time: Dec 15, 1991
Type of aircraft:
Operator:
Registration:
DQ-FEE
Flight Type:
Survivors:
Yes
Schedule:
Suva - Suva
MSN:
14057
YOM:
1955
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew (one pilot and one instructor) was completing a local training flight at Suva Airport. On approach, the crew failed to lower the landing gear, causing the aircraft to land on its belly. It slid on the runway for few dozen metres before coming to rest. Both pilots escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The crew failed to follow the approach and landing checklist and forgot to lower the landing gear.

Crash of a Pilatus PC-6/B1-H2 Turbo Porter in Jaspers Brush: 2 killed

Date & Time: Nov 12, 1991
Operator:
Registration:
A14-683
Flight Phase:
Survivors:
Yes
Schedule:
Jaspers Brush - Jaspers Brush
MSN:
683
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
7415
Circumstances:
Crashed in unknown circumstances after takeoff from Jaspers Brush Airfield. Two occupants were killed and eight others were injured.

Crash of a Boeing 707-368C off Woodside Beach: 5 killed

Date & Time: Oct 29, 1991 at 1147 LT
Type of aircraft:
Operator:
Registration:
A20-103
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Richmond - §Avalon
MSN:
21103
YOM:
1975
Flight number:
Windsor 380
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The aircraft departed Richmond on a flight to Avalon, carrying five crew members. While cruising at an altitude of 5,000 feet along the coast, the aircraft lost height and plunged in the sea. The wreckage was found about one km off Woodside Beach and all five occupants were killed. At the time of the accident, weather conditions were good.
Crew:
Cpt Mark Lewin, pilot,
F/Lt Tim Ellis, copilot,
F/Lt Mark Duncan, pilot,
W/O Jon Fawcett, flight engineer,
W/O Al Gwynne, loadmaster.
Probable cause:
The Board of Inquiry concluded that the instructor devised a demonstration of asymmetric flight that was 'inherently dangerous and that was certain to lead to a sudden departure from controlled flight' and that he did not appreciate this. The Board noted there were deficiencies in the acquisition and documentation of 707 operational knowledge within the RAAF combined with the absence of effective mechanisms to prevent the erosion of operational knowledge at a time when large numbers of pilots were resigning from the air force. There was no official 707 QFI conversion course and associated syllabus and no adequate QFI instructors' manual. There were deficiencies in the documented procedures and limitations pertaining to asymmetric flight in the 707 and a lack of fidelity in the RAAF 707 simulator in the flight regime in which the accident occurred, which, assuming such a requirement existed, required actual practise in flight. 'The captain acted with the best of intentions but without sufficient professional knowledge or understanding of the consequences of the situation in which he placed the aircraft,' the Board said.