Crash of an IAI-1124A Westwind II off Norfolk Island

Date & Time: Nov 18, 2009 at 2156 LT
Type of aircraft:
Operator:
Registration:
VH-NGA
Flight Type:
Survivors:
Yes
Schedule:
Apia - Norfolk Island - Melbourne
MSN:
387
YOM:
1983
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3596
Captain / Total hours on type:
923.00
Copilot / Total flying hours:
1954
Copilot / Total hours on type:
649
Aircraft flight hours:
21528
Aircraft flight cycles:
11867
Circumstances:
On 18 November 2009, the flight crew of an Israel Aircraft Industries Westwind 1124A aircraft, registered VH-NGA, was attempting a night approach and landing at Norfolk Island on an aeromedical flight from Apia, Samoa. On board were the pilot in command and copilot, and a doctor, nurse, patient and one passenger. On arrival, weather conditions prevented the crew from seeing the runway or its visual aids and therefore from landing. The pilot in command elected to ditch the aircraft in the sea before the aircraft’s fuel was exhausted. The aircraft broke in two after ditching. All the occupants escaped from the aircraft and were rescued by boat.
Probable cause:
The pilot in command did not plan the flight in accordance with the existing regulatory and operator requirements, precluding a full understanding and management of the potential hazards affecting the flight. The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination. The flight crew’s delayed awareness of the deteriorating weather at Norfolk Island combined with incomplete flight planning to influence the decision to continue to the island, rather than divert to a suitable alternate.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Kokoda: 13 killed

Date & Time: Aug 11, 2009 at 1114 LT
Operator:
Registration:
P2-MCB
Survivors:
No
Site:
Schedule:
Port Moresby - Kokoda
MSN:
441
YOM:
1975
Flight number:
CG4684
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
13
Captain / Total flying hours:
2270
Captain / Total hours on type:
1970.00
Copilot / Total flying hours:
2150
Copilot / Total hours on type:
1940
Aircraft flight hours:
46700
Circumstances:
On 11 August 2009, a de Havilland Canada DHC-6 Twin Otter aircraft, registered P2-MCB, with two pilots and 11 passengers, was being operated on a scheduled regular public transport service from Port Moresby to Kokoda Airstrip, Papua New Guinea (PNG). At about 1113, the aircraft impacted terrain on the eastern slope of the Kokoda Gap at about 5,780 ft above mean sea level in heavily-timbered jungle about 11 km south-east of Kokoda Airstrip. The aircraft was destroyed by impact forces. There were no survivors. Prior to the accident the crew were manoeuvring the aircraft within the Kokoda Gap, probably in an attempt to maintain visual flight in reported cloudy conditions. The investigation concluded that the accident was probably the result of controlled flight into terrain: that is, an otherwise airworthy aircraft was unintentionally flown into terrain, with little or no awareness by the crew of the impending collision.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain, 11 km south-east of Kokoda Airstrip, Papua New Guinea, involving a de Havilland Canada DHC-6-300 Twin Otter aircraft, registered P2-MCB, and should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing safety factors:
• Visual flight in the Kokoda Gap was made difficult by the extensive cloud coverage in the area.
• The crew attempted to continue the descent visually within the Kokoda Gap despite the weather conditions not being conducive to visual flight.
• It was probable that while manoeuvring at low level near the junction of the Kokoda Gap and Kokoda Valley, the aircraft entered instrument meteorological conditions.
• The aircraft collided with terrain in controlled flight.
Other safety factors:
• The copilot was assessed during normal proficiency checks for instrument approach procedures but was not qualified for flight in instrument meteorological conditions.
• The operator did not have a published emergency recovery procedure for application in the case of inadvertent flight into instrument meteorological conditions.
• The Civil Aviation Safety Authority Papua New Guinea surveillance of the operator did not identify the operations by the operator in contravention of Rule 91.112.
• The lack of a reliable mandatory occurrence reporting arrangement minimized the likelihood of an informed response to Papua New Guinea-specific safety risks.
• There was no qualified Director (or similar) of Aviation Medicine in Papua New Guinea (PNG).
• The lack of both flight data and cockpit voice recorders adversely affected a full understanding of the accident by the investigation.
Other key findings:
• The investigation was unable to discount the possible incapacitation of the copilot as a factor in the accident.
• Although not required by the aviation rules at the time of the accident, the adoption of threat and error management training for flight crews, and of the methodology by operators would provide a tool to identify and mitigate operational risk as follows:
– by flight crews, when flight planning and during flight; and
– by operators, when developing their operational procedures.
Final Report:

Crash of a Britten Norman BN-2A Trislander III-1 on Great Barrier Island

Date & Time: Jul 5, 2009 at 1305 LT
Type of aircraft:
Operator:
Registration:
ZK-LOU
Flight Phase:
Survivors:
Yes
Schedule:
Great Barrier Island - Auckland
MSN:
322
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
868
Captain / Total hours on type:
28.00
Circumstances:
At about 1300 on Sunday 5 July 2009, ZK-LOU, a 3-engined Britten Norman BN2A Mk III Trislander operated by Great Barrier Airlines (the company), took off from Great Barrier Aerodrome at Claris on Great Barrier Island on a regular service to Auckland International Airport. On board were 10 passengers and a pilot, all of whom were wearing their seat belts. That morning the pilot had flown a different Trislander from Auckland International Airport to Claris and swapped it for ZK-LOU for the return flight because it was needed for pilot training back in Auckland. Another company pilot had that morning flown ZK-LOU to Claris from North Shore Aerodrome. He had completed a full engine run-up for the first departure of the day, as was usual, and said he noticed nothing unusual with the aeroplane during the approximate 30-minute flight. For the return flight the pilot said he completed the normal after-start checks in ZK-LOU and noticed nothing abnormal. He did not do another full engine run-up because it was not required. He taxied the aeroplane to the start of sealed runway 28, applied full power while holding the aeroplane on brakes and rechecked that the engine gauges were indicating normally before starting the take-off roll. The aeroplane took off without incident, but the pilot said when it was climbing through about 500 feet he heard an unusual “pattering” sound. He also heard the propellers going out of synchronisation, so he attempted to resynchronise them with the propeller controls. He checked the engine’s gauges and noticed that the right engine manifold pressure and engine rotation speed had dropped, so he adjusted the engine and propeller controls to increase engine power. At that time there was a loud bang and he heard a passenger scream. Looking back to his right the pilot saw that the entire propeller assembly for the right engine was missing and that there was a lot of oil spray around the engine cowling. The pilot turned the aeroplane left and completed the engine failure and shutdown checks. He transmitted a distress call on the local area frequency and asked the other company pilot, who was airborne behind him, to alert the local company office that he was returning to Claris. The company office manager and other company pilot noticed nothing unusual with ZK-LOU as it taxied and took off. The other pilot was not concerned until he saw what looked like white smoke and debris emanate from the aeroplane as though it had struck a flock of birds. Despite the failure, ZK-LOU continued to climb, so the pilot said he levelled at about 800 feet and reduced power on the 2 serviceable engines, completed a left turn and crossed over the aerodrome and positioned right downwind for runway 28. There was quite a strong headwind for the landing, so the pilot elected to do a flapless landing and keep the power and speed up a little because of the possibility of some wind shear. The pilot and other personnel said that the cloud was scattered at about 2500 feet, that there were a few showers in the area and that the wind was about 15 to 20 knots along runway 28. The visibility was reported as good. After landing, the pilot stopped the aeroplane on the runway and checked on the passengers before taxiing to the apron. At the apron he shut down the other engines and helped the passengers to the terminal, where they were offered drinks. The company chief executive, who lived locally, and a local doctor attended to the passengers. Three of the passengers received some minor abrasions and scrapes from shattered Perspex and broken interior lining when the propeller struck the side of the fuselage.
Probable cause:
Findings are listed in order of development and not in order of priority.
- The engine propeller assembly separated from the right engine of ZK-LOU in flight and struck the fuselage when the crankshaft failed at the flange that connected it to the propeller hub.
- High-cycle fatigue cracking on the flange that had developed during normal operations from undetected corrosion had reached a critical stage and allowed the flange to fail in overload.
- The crankshaft had inadvertently passed its overhaul service life by around 11% when the failure occurred, but the company had not realized this because of an anomaly in the recorded overseas service hours prior to importation of the engine to New Zealand. Ordinarily, the crankshaft would have been retired before a failure was likely.
- The crankshaft was an older design that has since been progressively superseded by those with flanges less prone to cracking.
- There was no requirement for a specific periodic crack check of the older-design crankshaft flanges, but this has been addressed by the CAA issuing a Continuing Airworthiness Notice on the issue.
- The CAA audit of the company had examined whether its engine overhaul periods were correct, but the audit could not have been expected to discover the anomaly in the overseas-recorded engine hours.
- This failure highlighted the need by potential purchasers of overseas components to follow the guidelines outlined in CAA Advisory Circular 00-1 to scrutinize overseas component records to ensure that the reported in-service hours are accurate.
Final Report:

Crash of a Piper PA-31 Navajo Chieftain in Darwin

Date & Time: Feb 6, 2009 at 0840 LT
Operator:
Registration:
VH-TFX
Flight Phase:
Survivors:
Yes
Schedule:
Darwin – Maningrida
MSN:
31-8152143
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Darwin Airport, while in initial climb, one of the engine failed. The pilot declared an emergency and elected to return but eventually attempted to ditch the aircraft that came to rest in shallow water about 200 metres offshore. All six occupants escaped uninjured while the aircraft was damaged beyond repair.

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

Date & Time: Dec 19, 2008 at 1110 LT
Type of aircraft:
Operator:
Registration:
YJ-RV2
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Olpoi - Luganville
MSN:
172
YOM:
1970
Flight number:
AVN261
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8395
Captain / Total hours on type:
1300.00
Aircraft flight hours:
15314
Aircraft flight cycles:
26340
Circumstances:
On Friday 19 December 2008, YJ-RV2, a Britten-Norman Islander aeroplane, was scheduled to fly a routine commercial passenger service for Air Vanuatu (Domestic) Limited (the operator). The service was to start from Bauerfield International Airport, Port Vila and was to include 5 flights or legs, taking the aircraft north via an intermediate landing at Norsup and onto Pekoa International Airport (also known as Santo Airport) near Luganville on Espiritu Santo. At Santo Airport the aircraft was to be refuelled and after a stopover of about 2 hours the service was to continue north to Gaua and Mota Lava before returning to Santo where it was planned to terminate. The pilot arrived at the operator’s base at about 0700 and started his before-flight duties. The flight departed Bauerfield on schedule at 0730 and progressed normally to Santo. The operator’s agent at Santo had early Friday morning called the company operations office in Port Vila and asked if a flight from Santo to Lajmoli and return could be added to the service. The regular Thursday flight had been cancelled and 9 passengers had been left stranded at Lajmoli. The operations staff approved the request and the agent advised he would confirm with the pilot of YJ-RV2 when he arrived at Santo. At Santo the pilot was met by the agent and agreed to the request for the additional flight to Lajmoli. No interruption to the original schedule was envisaged as the flight should have returned to Santo well before the planned 1230 departure north to Gaua. The aircraft was checked and 246 litres of fuel were added. The aircraft departed Santo for Lajmoli at 1016 with the pilot and 4 passengers onboard. At Lajmoli, the local agent, aware that YJ-RV2 was inbound, weighed the passengers and their bags in preparation for the return flight. At 1043 YJ-RV2 landed at Lajmoli and the agent off-loaded the passengers and baggage while the pilot waited by the aircraft. The agent later reported that he informed the pilot of the planned load of 9 passengers and baggage, and that the aircraft would likely be at about maximum allowable weight. The pilot was reported to have advised the agent that he was happy to continue and instructed him to load the aircraft. The pilot remained near the aircraft while the agent loaded first the baggage then the passengers. The pilot instructed one of the passengers to enter the aircraft through the forward door and sit in the front-right seat next to the pilot. The agent added the weight of the passengers and baggage to the load sheet for the flight, but he wasn’t aware of the fuel weight so omitted this from the sheet. The load sheet, which included a passenger manifest, was returned to the pilot, who signed it. A copy was retained by the agent and later handed to the investigation team. At 1055 the pilot started the engines and taxied the aircraft for grass runway 14. YJ-RV2 took off at 1058 and at 1100 the pilot called Santo air traffic services on the high frequency (HF) radio,reporting airborne and climbing to 7000 feet. He gave an estimated time of arrival at Santo of 130. Witnesses, both on the ground at Lajmoli and passengers on board, later commented that the aircraft took longer to get airborne than normal and was slower to climb. The pilot followed the coastline south and approaching the village of Wunavae turned left inland. Passengers later commented that the aircraft flew in a direct line towards the rising hilly ground and, based on their previous flying experiences, crossed several ridges at a lower-than-normal height. The passengers also commented that the pilot increased power on the engines as they flew in an easterly direction. The passengers later spoken to (7) reported no significant turbulence and while there was perhaps some light cloud about, they were able to see the terrain ahead. The passengers recalled becoming increasingly concerned about the low height of the aircraft as it flew directly at a right-angle towards the last ridgeline before crossing over into Big Bay. Some of the passengers described the pilot closing the throttles and shutting down the engines as they approached the ridgeline. At about the same time they heard a loud buzzing sound, later identified as the aircraft’s stall warning. Shortly afterwards, the aircraft struck the trees and bush and quickly came to a halt. No communication was heard from the pilot during this time, although he was observed throughout making movements typical of someone who was awake. Within a couple of minutes of impacting into the bush, the passengers started vacating the aircraft. Fuel was smelled about the aircraft and seen dripping from the wing. The passengers were unable to rouse the pilot and front-seat passenger, who were trapped in the now-deformed front of the aircraft. A second passenger, who had suffered a severe head wound and suspected broken leg, was slower to vacate the aircraft and remained semi-conscious near its right side. The remaining 7 passengers assembled at the rear of the aircraft, near the rear left baggage door. Thinking that the pilot and front-seat passenger were dead, and fearing the aircraft might catch fire, they agreed to start walking downhill towards the coast and Wunavae village. The eighth passenger, now aware that the main group had departed downhill, attempted to follow but was unable to catch up owing to his injuries. At about 1115, Santo air traffic services called the pilot of YJ-RV2 to coordinate his arrival with those of several other aircraft also approaching Santo. The controller received no response, so requested other aircraft to call YJ-RV2 on various radio frequencies. Again there was no response. At 1130 the controller declared the aircraft overdue and informed the authorities and the operator. The crews of a company ATR 42 and a DH6 Twin Otter on scheduled local flights were asked to conduct an initial search for YJ-RV2, focusing on the direct track from Lajmoli to Santo. A third private aircraft also assisted in the search. At about 1245 the crew of the ATR 42 located the wreckage of YJ-RV2 at about 4000 feet (1200 m) in the mountainous area west of Big Bay. The crew was unable to fly close enough to confirm if there were any survivors. At 1500, a light helicopter based in Port Vila departed for Santo and the accident site. Inclement weather prevented the helicopter reaching the site that evening and rescue operations were halted until the next day. Additional support was also requested from New Caledonia, and a French military Super Puma helicopter and medical team arrived in Santo on Saturday morning. At about 0700 on Saturday 20 December, the first rescue personnel reached YJ-RV2 and confirmed that the pilot was dead and the front-seat passenger critically injured. There was no sign of the remaining 8 passengers. The critically injured passenger was initially evacuated to Luganville Hospital and was subsequently taken to Australia for further treatment. He died of his injuries on 1 January 2009. During Saturday morning a group of searchers from Wunavae village started walking towards the accident site looking for survivors. About mid-afternoon, the group of 7 passengers was located by the crew of the Super Puma some 3 to 4 km west of the accident site and airlifted to Santo for treatment. The last passenger was located by the villagers the following day and after a third night in the bush was airlifted to hospital.
Probable cause:
Findings:
Findings are listed in order of development and not in order of priority.
- The pilot was appropriately licensed to fly the aeroplane, but his route and aerodrome qualification had been allowed to lapse. However, this lapse was unlikely to have contributed to the accident.
- There was no evidence that the pilot was not fit to conduct the flight, but he was observed by the local agent and passengers to be less communicative than usual, both before and during the flight.
- The aeroplane had been maintained in accordance with approved standards and there was no evidence of mechanical failure that could have contributed to the accident.
- The weather was suitable for the pilot to maintain appropriate terrain separation visually.
- The aeroplane was overloaded by at least 7%, which affected its climb performance and made it unlikely that it would be able to cross the final ridge without deviating from the path flown by the
pilot.
- The aeroplane did not have sufficient height margin to approach the lee of the ridge where downdraughts were foreseeable, and the pilot had not approached the ridge from a direction that
would have afforded him an escape route when he decided to abort the crossing.
- The poor configuration of the seat belts in the aeroplane increased the risk of injury to the occupants, and may have contributed to the death of one passenger.
- The chances of survival for those passengers who survived the impact were reduced by their decision to leave the accident site.
Final Report:

Crash of a PAC Cresco 08-600 in Tarata: 1 killed

Date & Time: Dec 14, 2008 at 1155 LT
Type of aircraft:
Operator:
Registration:
ZK-LTC
Flight Phase:
Survivors:
No
Schedule:
Tarata - Tarata
MSN:
20
YOM:
1997
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
12100
Aircraft flight hours:
3272
Aircraft flight cycles:
33147
Circumstances:
On Sunday 14 December 2008, the aircraft departed from Stratford Aerodrome at 0630 hours for a transit flight to a farm airstrip near Tarata. Shortly after becoming airborne the pilot noticed the engine chip detector warning light on the instrument panel was illuminated. He diverted to the company maintenance base at Wanganui aerodrome for the defect to be rectified. The aircraft engineer found a light metallic fuzz on the engine magnetic (mag) plug. The fuzz was cleaned off and the mag plug refitted. The aircraft was released to service with a condition that a further inspection of the mag plug was to be performed after 10 hours flight time. The topdressing job, which involved the spreading of 450 tonnes of lime, had commenced on Thursday 11 December 2008 and continued on Friday 12 December 2008. No flying took place on Saturday 13 December 2008 due to a local horse-riding event being held on the farm property. The aircraft arrived at the farm airstrip at 0940 hours on the Sunday morning, and shortly thereafter commenced operations to complete the spreading of the lime. At the time of the accident, 423 tonnes of lime had been spread. The pilot flew a series of topdressing flights before needing to stop for the first refuel. When interviewed, the loader driver stated that the pilot informed him that he was having some difficulty with the lime product not flowing consistently from the aircraft hopper during the sowing runs. At approximately 1145 hours the pilot stopped again to refuel. On completion of the refuel, this gave the aircraft an estimated fuel load of 300 litres. The pilot completed a further two flights. On the third flight, the aircraft became airborne at the end of the airstrip and then descended 55 feet below the level of the airstrip where the aft fuselage struck a fence line. A concentration of lime along the aircraft’s take-off path indicated that the pilot had initiated an attempt to jettison his load at the end of the airstrip. Following the collision with the fence, the aircraft remained airborne for a further 450 metres before it impacted the side of a small hill in a slight nose down attitude. The aircraft then came to rest 12 metres to the left of the initial impact point. The accident occurred in daylight, at approximately 1155 hours NZDT, at Tarata, at an elevation of 410 feet amsl. Latitude: S39° 08.169', longitude: E174° 21.710'.
Probable cause:
Conclusions:
- The pilot was appropriately licensed, held the appropriate Medical Certificate, was experienced and fit to carry out aerial topdressing operations.
- The aircraft had been operating normally from the airstrip up to the time of the accident.
- The aircraft descended after take-off and struck a fence. The collision with the fence damaged the elevator control cable system which jammed the elevator control surface. This resulted in the pilot being unable to adequately control the aircraft in pitch, and the aircraft subsequently struck the ground.
- The aircraft was loaded with 1900 kg of lime product on the accident flight, this was in excess of the 1860 kg maximum structural hopper load. No variation above the maximum structural hopper load is allowed for in CAR Part 137. The aircraft’s all-up weight at the time of the accident was under the maximum allowed under the overload provisions of CAR Part 137 by 145 kg.
- The Aircraft Flight Manual does not provide take-off performance data for operation over the maximum certificated take-off weight and up to the maximum agricultural weight as allowed by CAR Part 137.
- A change in wind direction had occurred in the late morning which may have presented the pilot with a slight tail-wind or possible low level turbulence, including down draught conditions, during and after take-off.
- The windsock was not in the most suitable position to indicate the wind conditions to the pilot.
- Partial or full load jettisons had taken place on previous flights, indicating that the pilot was having difficulty achieving the required aircraft performance during or after take-off.
- On the accident flight, the aircraft was probably overloaded for the prevailing environmental conditions.
- The reported poor flowing qualities of the lime product being spread may have hampered the pilot’s efforts to jettison the load after take-off. The effectiveness of the jettison may have also been reduced by the downward flight path of the aircraft on leaving the end of the airstrip. It is unlikely that the pilot could comply with the CAR Part 137.103 requirement to jettison 80% of the load within five seconds.
- The possibility of a pre-existing airframe or engine defect that could have contributed to the accident was eliminated as far as practicable by the investigation.
- The ELT fitted to the aircraft was no longer an approved type, therefore the aircraft was not airworthy in accordance with CARs. The ELT was incapable of being detected by satellite and therefore would not automatically alert rescue services, however, this did not hamper rescue efforts in this accident.
- The accident was not survivable.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Bathurst: 4 killed

Date & Time: Nov 7, 2008 at 2024 LT
Registration:
VH-OPC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Melbourne – Bathurst – Port Macquarie
MSN:
31-7952082
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2061
Aircraft flight hours:
11000
Circumstances:
On 7 November 2008, a Piper Aircraft Corp. PA-31-350 Chieftain, registered VH-OPC, was being operated on a private flight under the instrument flight rules (IFR) from Moorabbin Airport, Vic. to Port Macquarie via Bathurst, NSW. On board the aircraft were the owner-pilot and three passengers. The aircraft departed Moorabbin Airport at about 1725 Eastern Daylight-saving Time and arrived at Bathurst Airport at about 1930. The pilot added 355 L of aviation gasoline (Avgas) to the aircraft from a self-service bowser and spent some time with the passengers in the airport terminal. Recorded information at Bathurst Airport indicated that, at about 2012 (12 minutes after civil twilight), the engines were started and at 2016 the aircraft was taxied for the holding point of runway 35. The aircraft was at the holding point for about 3 minutes, reportedly at high engine power. At 2020, the pilot broadcast that he was entering and backtracking runway 35 and at 2022:08 the pilot broadcast on the common traffic advisory frequency that he was departing (airborne) runway 35. At 2023:30, the pilot transmitted to air traffic control that he was airborne at Bathurst and to standby for departure details. There was no record or reports of any further radio transmissions from the pilot. At about 2024, a number of residents of Forest Grove, a settlement to the north of Bathurst Airport, heard a sudden loud noise from an aircraft at a relatively low height overhead, followed shortly after by the sound of an explosion and the glow of a fire. A witness located about 550 m to the south-west of the accident site, reported seeing two bright lights that were shining in a constant direction and ‘wobbling’. There was engine noise that was described by one witness as getting very loud and ‘rattling’ or ‘grinding’ abnormally before the aircraft crashed. At 2024:51, the first 000 telephone call was received from witnesses and shortly after, emergency services were notified. The aircraft was seriously damaged by impact forces and fire, and the four occupants were fatally injured.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain involving Piper Aircraft Corp. PA-31-35 Chieftain, registered VH-OPC, 3 km north of Bathurst Airport on 7 November 2008 and should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing safety factors:
• The aircraft descended at a steep angle before impacting the ground at high speed, consistent with uncontrolled flight into terrain.
Other key findings:
• Based on analysis of the available information, an airworthiness issue was considered unlikely to be a contributing factor to this accident.
• The investigation was unable to establish why the aircraft collided with terrain; however, pilot spatial disorientation or pilot incapacitation could not be discounted.
Final Report:

Crash of a Gippsland GA8 Airvan in the Buckingham Bay: 1 killed

Date & Time: Oct 16, 2008 at 0945 LT
Type of aircraft:
Registration:
VH-WRT
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Elcho Island – Mata Mata – Muthamul –Nyinyikay – Rurruwuy – Elcho Island
MSN:
GA8-01-005
YOM:
2001
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1300
Captain / Total hours on type:
300.00
Aircraft flight hours:
4750
Circumstances:
On the morning of 16 October 2008, a Gippsland Aeronautics GA8 Airvan, registered VH-WRT, was being operated on a freight charter flight from Elcho Island and return, Northern Territory. At about 1230, it was realised that the aircraft was missing. A witness reported seeing the aircraft during the early stages of the flight and, shortly afterwards, a column of dark black smoke rising from the eastern side of the Napier Peninsula. On 17 October 2008, items of wreckage from the aircraft were found in the south-western part of Buckingham Bay. The pilot, who was the sole occupant of the aircraft, and the main wreckage of the aircraft have not been found. After consideration of the available evidence, the investigation was unable to identify any factor that contributed to the accident.
Probable cause:
Following a review of the available evidence covering:
• Witness information,
• The pilot's fatigue and health,
• The airworthiness of the aircraft,
• Aircraft fuel,
• The weather affecting the flight, and
• The aircraft’s loading and weight and balance,
The investigation was unable to identify any factors that may have contributed to the accident. From the evidence available, the following findings are made with respect to the missing aircraft at Buckingham Bay, Northern Territory on 16 October 2008 involving Gippsland Aeronautics GA8 Airvan aircraft, registered VH-WRT. They should not be read as apportioning blame or liability to any organisation or individual. No contributing safety factors were identified.
Other safety factors:
• The main vertical net and the throwover net were not used to restrain the cargo.
• The full jerry cans were not secured in the aircraft cabin.
• At the time of departure, the aircraft’s centre of gravity (c.g) was probably to the rear of the permitted c.g limit that was published in the Aircraft Flight Manual.
• There was no record that the pilot lodged a flight notification for the flight with Airservices Australia.
Final Report:

Crash of a Gippsland GA8 Airvan in Cooinda

Date & Time: Sep 9, 2008 at 1500 LT
Type of aircraft:
Operator:
Registration:
VH-KNE
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cooinda - Cooinda
MSN:
GA8-08-128
YOM:
2008
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot was completing a local post maintenance test flight at Cooinda Airport. Shortly after takeoff, while in initial climb, the engine failed. The pilot attempted an emergency landing in the bush but the aircraft collided with a telephone pole and came to rest. The pilot escaped with minor injuries and the aircraft was damaged beyond repair.
Probable cause:
Engine failure for unknown reasons.

Crash of a De Havilland DHC-4A Caribou in Efogi

Date & Time: Sep 5, 2008
Type of aircraft:
Operator:
Registration:
A4-285
Flight Type:
Survivors:
Yes
MSN:
285
YOM:
1969
Location:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Damaged beyond repair following structural failure due to fatigue upon landing at Efogi, PNG. There were no injuries but the aircraft was damaged beyond repair and dismantled.