Crash of an Embraer EMB-110P1 Bandeirante near Kandrian: 2 killed

Date & Time: Mar 30, 2007 at 0523 LT
Operator:
Registration:
P2-ALU
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Port Moresby – Hoskins – Rabaul
MSN:
110-232
YOM:
1979
Flight number:
ND304
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4653
Captain / Total hours on type:
1253.00
Copilot / Total flying hours:
4235
Copilot / Total hours on type:
610
Aircraft flight hours:
36962
Aircraft flight cycles:
43756
Circumstances:
The aircraft was refueled with 640 litres (L) of Jet-A1 (AVTUR) in preparation for an early morning departure to Hoskins, New Britain, on 30 March. On 30 March, the crew lodged a flight plan, which stated that the total fuel on board was 2,100 pounds (lbs) (1,208 L). The first sector of the planned route was from Port Moresby to Hoskins. The pilot-in-command (PIC) obtained an area forecast for the flight, which indicated that there were areas of rain and scattered cloud from 1500-5000 feet (ft), with deteriorating conditions forecast for the period between 0400-0800 hours (hrs); for their arrival at Hoskins. The forecast required 30 minutes holding fuel in addition to the flight and statutory fuel requirements. These conditions were normal for their destination at this time of the year.The aircraft departed Port Moresby at 0402, as flight number ND304 for Hoskins. It initially climbed to the planned Flight Level (FL) 140 (14,000 ft), which was 300 ft above the lowest safe altitude (LSA) on the initial RNC track between Port Moresby and Girua, an Instrument Flight Rules (IFR) reporting point on the north coast of the PNG mainland. The LSA for the sector between Girua and the en-route reporting point Maran was 3,300 ft, and the PIC had planned to cruise at 9,000 ft. The sector between Maran and Hoskins was planned at 9,000 ft, with a LSA of 8,300 ft. The purpose of the flight was to transport newspapers and general freight to Hoskins and Rabaul. Flight Information Area (FIA) communications with Nadzab Flight Service used High Frequency (HF) radio, and a Very High Frequency (127.1 MHz) repeater transceiver located near the township of Popondetta. This service was usually monitored by Nadzab Flight Service during their normal hours of operation, for aircraft operating on the Girua to Hoskins track. One of the functions of the Nadzab Flight Service Unit was to record all transmissions received via the Girua repeater site. The crew made a position report, intercepted by Port Moresby Flight Service, advising that they were overhead Maran at 0506, cruising at FL 110 (11,000 ft), and gave an estimated time of arrival (ETA) Hoskins at 0540. That was 2,000 ft higher than the planned level. The position report was received by Port Moresby Flight Service, because Nadzab Flight Service had not commenced operations. It subsequently commenced operations for the day at 0540. Because Nadzab was responsible for the airspace in which ALU was operating, Port Moresby Flight Service advised Nadzab of ALU’s position report, once Nadzab opened. The Maran position report was the last recorded radio contact with the aircraft. No transmission declaring the intention to descend below FL110 was heard from the crew of ALU. No MAYDAY transmission was reported by ATS or other aircrew. When the crew of ALU failed to report their arrival at Hoskins, a search was commenced of the Hoskins aerodrome. At 0650 a DISTRESFA Search and Rescue Phase (SAR) was declared indicating the degree of apprehension held for the safety of the aircraft and its occupants. Later that morning verbal reports were received from a coastal logging company in an area east of Kandrian, that an aircraft had crashed. The wreckage of ALU was found 27 km east of Kandrian, at an elevation of 780 ft above sea level. Both crew members had not survived the impact. The wreckage was located at position 06° 11′ 39.8′′ S, 149° 52′ 58.9′′ E, and was dispersed along a 500 m wreckage trail after colliding with numerous trees and impacting the terrain. The investigation estimated the time of the accident to be about 0523.
Probable cause:
The reason the crew were unable to maintain level flight above the en-route lowest safe altitude with one engine inoperative, and subsequently impacted terrain, could not be determined.
Final Report:

Crash of a Britten-Norman BN-2A-27 Islander off Tauranga

Date & Time: Dec 28, 2006 at 1000 LT
Type of aircraft:
Operator:
Registration:
ZK-WNZ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tauranga - Hamilton
MSN:
278
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot was ferrying the aircraft from Tauranga to a Hamilton maintenance facility when one of the engines failed. The pilot elected to turn back to Tauranga but, shortly after, the remaining engine failed. The pilot carried out a forced landing into a tidal estuary. The aircraft incurred substantial damage to the nose landing gear. Subsequent CAA safety investigation determined that on an earlier flight, the aircraft's electrical system incurred a defect that rendered several electrical components unserviceable, including the two tip/main fuel tank selector valves. No engineering inspection or rectification ensued and the operator ferried the aircraft from Great Barrier Island unaware that the engines were being fed from the tip tanks only. The operator departed Tauranga for Hamilton under similar circumstances, reaching the vicinity of the Kaimai Ranges when the tip tanks became empty.
Probable cause:
Fuel exhaustion.

Crash of a Partenavia P.68B Victor off Rottnest Island

Date & Time: Nov 12, 2006 at 1500 LT
Type of aircraft:
Operator:
Registration:
VH-IYK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Rottnest Island - Perth
MSN:
138
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Rottnest Island Airport, while in initial climb, the twin engine aircraft suffered a bird strike and crashed in a salt lake located near the airport. The aircraft was destroyed upon impact and all six occupants were injured.
Probable cause:
Loss of control during initial climb following a bird strike.

Crash of a Piper PA-31-350 Navajo Chieftain near Raglan: 3 killed

Date & Time: Oct 31, 2006 at 1855 LT
Operator:
Registration:
VH-ZGZ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Emerald – Gladstone
MSN:
31-7752006
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
3900
Captain / Total hours on type:
70.00
Aircraft flight hours:
3977
Circumstances:
The aircraft was being operated on a private category instrument flight rules (IFR) flight from Emerald to Gladstone, Qld. On board the aircraft were the pilot in command and two passengers. One of the passengers was a qualified pilot, but who was not endorsed on the aircraft type. After departing Emerald at 1807 Eastern Standard Time, the pilot contacted air traffic control and reported climbing to 7,000 ft with an estimated time of arrival at Gladstone of 1915. At 1813:25, air traffic control advised the pilot that ZGZ was radar identified 15 NM east of Emerald. At 1815:12, the pilot requested clearance to climb to 9,000 ft. At 1817:05, air traffic control issued a clearance to the pilot for the aircraft to climb 9,000 ft, and to track direct to Gladstone. At 1820:26, the pilot reported level at 9,000 ft and requested clearance to divert up to 10 NM left and right of track to avoid anticipated weather activity ahead. Air traffic control approved that request. At 1830:56, the pilot requested clearance to divert up to 15 NM left and right of track, and 10 seconds later changed the request to 15 NM left of track. Air traffic control approved that request. At 1835:17, the pilot reported clear of the weather and requested clearance to track direct to Gladstone and to descend to 7,000 ft. Air traffic control approved those requests. At 1848:52, the pilot reported at ‘top of descent’ to Gladstone. Air traffic control cleared the pilot to descend. At 1852:45, the pilot reported changing frequency to the Gladstone common traffic advisory frequency (CTAF). Air traffic control advised the pilot that the aircraft was leaving 5,500 ft and that the radar and control services were terminated. The pilot acknowledged that transmission at 1852:57. Approximately 3 minutes later, at 1855:45, air traffic control noticed that the aircraft’s symbol was no longer evident on the air situation display screen and the controller attempted to contact the pilot of the aircraft by radio. The controller also requested pilots of other aircraft operating in the Gladstone area to attempt to contact the pilot of ZGZ on the Gladstone CTAF frequency. All attempts were unsuccessful. A witness in the Raglan area recalled hearing the sound of aircraft engine(s) overhead. He then heard the engine(s) ‘roar and shut off again’ a few times. A short time later, he saw a flash and a few seconds later heard the sound of an explosion. He realised that the aircraft had crashed and telephoned the Gladstone Police. Subsequently, wreckage of the aircraft was located near Raglan, approximately 39 km west of Gladstone. The three occupants were fatally injured. The aircraft was destroyed by impact forces and post-impact fire.
Probable cause:
From the evidence available, the following findings are made with respect to the loss of control event involving Piper Aircraft Corporation PA-31-350 aircraft registered VH-ZGZ and should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing safety factors:
• The aircraft diverged left from a steady, controlled descent and entered a steep, left spiral descent from which recovery was not achieved.
Other safety factors:
• The dark and very likely cloudy conditions that existed in the area where the aircraft suddenly diverged from its flight path meant that recovery to normal flight could only have been achieved by sole reference to the aircraft’s flight instruments. The difficulty associated with such a task when the aircraft was in a steep descent was likely to have been significant.
Final Report:

Crash of a Swearingen SA227AC Metro III in Canberra

Date & Time: Jul 1, 2006
Type of aircraft:
Operator:
Registration:
VH-VEH
Survivors:
Yes
MSN:
AC-663B
YOM:
1986
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
By night, the twin engine aircraft landed hard at Canberra Airport. There were no injuries but the aircraft was damaged beyond repair.
Probable cause:
ATSB did not conduct any investigations on this event.

Crash of a Fletcher FU-24-950 near Kaitaia: 1 killed

Date & Time: Mar 31, 2006 at 1345 LT
Type of aircraft:
Operator:
Registration:
ZK-EGP
Flight Phase:
Survivors:
No
Site:
Schedule:
Kaitaia - Kaitaia
MSN:
238
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1347
Captain / Total hours on type:
864.00
Aircraft flight hours:
11230
Circumstances:
On Friday 31 March 2006 the pilot intended to carry out topdressing on properties near a steep hill range nine kilometres to the south-west of Kaitaia. The day’s activities commenced at approximately 0600 hours when the pilot and loaderdriver met at Kaitaia aerodrome. The pilot and loader-driver flew in the aircraft from the aerodrome to a farm airstrip located on the back of a hill range near the Pukepoto Quarry where the fertiliser-loading truck had been parked overnight. The topdressing operation began in the morning with spreading approximately 25 tonnes of superphosphate on nearby farmland which was stored in the fertiliser bins next to the airstrip. As the last of the superphosphate was being spread, a consignment of fresh lime was delivered by a trucking contractor. The topdressing operation continued with the spreading of the lime on another property near the base of the hill range, about three kilometres from the airstrip. At around 1000 hours, while waiting on another delivery of lime by the trucking contractor, the pilot and loader-driver flew in the aircraft to another airstrip about 20 km to the south-east near Broadwood. They repositioned a fertiliser-loading truck located at this airstrip to another airstrip near Pawarenga, in anticipation of the next day’s topdressing. The pilot and loader-driver then flew back to the original farm airstrip near the Pukepoto Quarry, arriving at approximately 1100 hours. At about this time the pilot received a cell phone call from his supervising Chief Pilot. During the conversation he asked the Chief Pilot for his advice about the best direction for spreading lime on the land that he was currently working on. The pilot also commented about how the lime was ‘hanging up’ and not flowing easily from the aircraft’s hopper. The Chief Pilot cautioned the pilot about the poor flow properties of new lime and advised him to spread the lime in line with the hill range, not up the slope. The topdressing operation then resumed until all the lime in the fertiliser bin had been used. The pilot and loader-driver then stopped for lunch during which time the aircraft was refuelled and another truckload of lime was delivered. The pilot had commented to the loader-driver during lunch that the lime was still hanging up in the aircraft’s hopper. He was finding that he needed to complete about two passes to clear the entire load from the hopper. Just before starting the afternoon’s topdressing flights, the pilot had a conversation on his cell phone with a bank manager in Auckland. The conversation concerned the financial position of his topdressing business. The loader-driver reported that the pilot became very agitated during the conversation, but appeared to calm down prior to beginning the afternoon’s flying. The farm-owner observed the aircraft on its first flight of the afternoon as it completed the first two passes. He was aware that the aircraft had flown further away after these two passes and assumed the aircraft was returning to the airstrip for a second load of lime. He did not notice anything abnormal about the aircraft. Other witnesses reported that the aircraft flew parallel with a plantation of 30-40 metre high trees towards the rising hill range. The closest eye witness reported seeing what appeared to be fertiliser dropping from the aircraft as it flew along the tree line up the slope. The dropping of the fertiliser then stopped at which point the aircraft was seen entering a steep right hand turn away from the slope whilst descending towards the ground. The aircraft disappeared in to tall bush on the hillside and witnesses heard the aircraft impact the ground. A large smoke-like cloud was then seen rising up through the bush. On hearing the impact, the farm-owner and a local share-milker from a nearby farm searched the hillside for the aircraft. The aircraft was obscured by the tall bush and was initially difficult to locate. The share-milker made his way down the hillside through the bush to the aircraft. He quickly realised that the pilot was deceased. The farmer-owner went to alert the emergency services, however another property owner who had heard the aircraft strike the ground and seen the smoke had already telephoned the New Zealand Police. The accident occurred in daylight, at approximately 1345 hours NZDT, 9 km south-west of Kaitaia at an elevation of 880 feet AMSL. Latitude: S 35° 10' 26.1", longitude: E 173° 11' 29.4"; grid reference: NZMS 260 N05 283698.
Probable cause:
Conclusions:
- The pilot was appropriately licensed and was being supervised as required by Civil Aviation Rules.
- The aircraft had been maintained in accordance with the requirements of Civil Aviation Rules, and had a valid airworthiness certificate.
- There was no evidence that the aircraft had suffered any mechanical problem which may have contributed to the accident.
- The probable initiator of the accident was a hung load of lime which would have limited the climb performance of the aircraft. Factors contributing to the accident were the steep rising terrain and a high tree line which restricted the turning options for the pilot.
- The pilot flew the aircraft into a situation where he had limited recovery options. Due to his limited agricultural flying experience, he may not have appreciated his predicament until it was too late or taken recovery action early enough. The aircraft appears to have aerodynamically stalled during a right hand turn from which there was insufficient height to recover.
- In addition, the pilot’s decision making ability and concentration may have been impaired to some degree by various distractions and fatigue.
- The accident was not survivable.
- The standard sight (observation) window installed on Fletcher aircraft is an impractical method for pilots to monitor the upper level of the hopper contents during flight, particularly with a product like lime which has a higher relative density compared to other fertiliser products.
Final Report:

Crash of a De Havilland DH.104 Dove 1B at Ohakea AFB

Date & Time: Feb 3, 2006 at 1020 LT
Type of aircraft:
Operator:
Registration:
ZK-UDO
Flight Type:
Survivors:
Yes
MSN:
04412
YOM:
1953
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was performing a private tour when enroute, the crew decided to divert to Ohakea AFB due to the deterioration of the weather conditions. On final approach, when full flaps was selected, the aircraft rolled left and right. The pilots could not control the aircraft that struck the runway surface and came to rest. While all occupants were uninjured, the aircraft was considered as damaged beyond repair.
Probable cause:
Failure of the port flap jack linkage eye-bolt which caused an asymmetrical flap condition, causing the aircraft to be out of control.

Crash of a Piper PA-31-350 Navajo Chieftain near Condobolin: 4 killed

Date & Time: Dec 2, 2005 at 1350 LT
Registration:
VH-PYN
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Brisbane – Swan Hill
MSN:
31-8252075
YOM:
1982
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
4600
Captain / Total hours on type:
1000.00
Aircraft flight hours:
2900
Circumstances:
On 2 December 2005, at 1122 Eastern Daylight-saving Time, a Piper Aircraft Corporation PA-31-350 Chieftain aircraft, registered VH-PYN (PYN), departed Archerfield, Qld, on a private flight to Griffith, NSW. The flight was planned under the instrument flight rules (IFR). On board the aircraft were the pilot, two passengers and an observer-pilot who was on the flight to gain knowledge of the aircraft operation. The aircraft tracked direct to Moree and then Coonamble at 10,000 ft, in accordance with the flight plan. At 1303, the pilot amended the destination to Swan Hill, Vic, tracking via Hillston, NSW. At 1314, the pilot advised air traffic control that the aircraft had passed overhead Coonamble at 1312 maintaining 10,000 ft, and was estimating Hillston at 1418. At 1316, the pilot reported that he was tracking 5 NM (9 km) left of track due to weather. At 1337, the pilot advised that he was diverting up to 20 NM (37 km) left of track due to weather. At 1348, the pilot reported that he was diverting 29 NM (54 km) left of track, again due to weather. No further radio transmission from the pilot was heard. At about 1400, police received a report that an aircraft had crashed on a property approximately 28 km north of Condobolin, NSW. The extensively burned wreckage was subsequently confirmed as PYN. Other wreckage, spread along a trail up to 4 km from the main wreckage, was located the following day. Examination of air traffic control recorded radar data indicated that the aircraft entered radar coverage about 50 km north of Condobolin at 1346:34. The last valid radar data from the secondary surveillance radar located on Mount Bobbara was at 1349:53. During that 3 minute 19 second period, the recorded aircraft track was approximately 56 km left of the Coonamble to Hillston track and showed a change in direction from southerly to south-westerly. The aircraft’s groundspeed was in the range between 200 and 220 kts. The aircraft’s altitude remained steady at 10,000 ft. The last recorded radar position of the aircraft was approaching the limit of predicted radar coverage and was within 10 km of the location of the main aircraft wreckage. Earlier that day, the aircraft had departed Bendigo, Vic, at 0602 and arrived at Archerfield at 1034. The pilot and the observer-pilot were on board. The aircraft was refuelled to full tanks with 314 litres of aviation gasoline at Archerfield. The refuelling agent reported that the main and auxiliary tanks were full at the completion of refuelling. He also reported that the pilots had commented that the forecast for their return flight indicated that weather conditions would be ‘patchy’.
Probable cause:
Contributing factors:
• A line of thunderstorms crossed the aircraft’s intended track.
• The aircraft was operating in the vicinity of thunderstorm cells.
• In circumstances that could not be determined, the aircraft’s load limits were exceeded, causing structural failure of the airframe.
Other safety factors:
• Air traffic control procedures, did not require the SIGMET information to be passed to the aircraft.
• There were shortcomings in the Airservices Australia Hazard Alert procedures and guidelines for assessing SIGMET information.
• Air traffic control procedures for the dissemination of SIGMET information contained in the Aeronautical Information Publication were inconsistent with procedures contained in International Civil Aviation Organization (ICAO) Doc. 4444 and ICAO Doc. 7030.
Other key findings:
• The aircraft was not equipped with weather radar or lightning strike detection systems.
• The pilot did not make any request for additional information regarding the weather to air traffic services.
• The pilot in command was occupying the right cockpit seat and the observer- pilot the left cockpit seat at the time of the breakup, but that arrangement was not considered to have influenced the development of the accident.
Final Report:

Crash of a Fletcher FU-24-950 in Whangarei: 2 killed

Date & Time: Nov 22, 2005 at 1142 LT
Type of aircraft:
Operator:
Registration:
ZK-DZG
Flight Type:
Survivors:
No
MSN:
207
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
16000
Captain / Total hours on type:
2382.00
Aircraft flight hours:
10597
Circumstances:
On 21 November 2005, the day before the accident, the pilot had completed a day of aerial topdressing in ZK-DZG, a New Zealand Aerospace Industries Fletcher FU24-950, then flown the aircraft with his loader-driver as a passenger to Whangarei Aerodrome. That evening the pilot contacted his operator’s (the company’s) chief engineer in Hamilton and said that the airspeed indicator in ZK-DZG was stuck on 80 knots. The chief engineer told him the pitot-static line for the indicator was probably blocked and to have a local aircraft engineer blow out the line. Early the next morning, the day of the accident, the pilot flew ZK-DZG with his loader-driver on board to an airstrip 50 km north-west of Whangarei to spread fertiliser on a farm property. As the morning progressed, the weather conditions became unsuitable for aerial topdressing. At about 1020, the pilot used his mobile telephone to talk to another company pilot at Kerikeri, and told him that the wind was too strong for further work. The conversation included general work-related issues and ended about 1045, with the pilot saying that he was shortly going to return to Whangarei and go to his motel. Before leaving for Whangarei, the pilot spoke with a truck driver who had delivered fertiliser to the airstrip about 1100. The driver commented later that the pilot said the wind had picked up enough to preclude further topdressing. After they had covered the fertiliser, the pilot told the driver that he and the loader-driver would fly to Whangarei. The driver did not recall anything untoward, except that the pilot had casually mentioned there was some electrical fault causing an amber light in the cockpit to flicker and that it would only be a problem if a second light came on. He said the pilot did not appear to be concerned about the light. The driver then left and did not see the aircraft depart. The pilot used his mobile telephone to tell an aircraft engineer at Whangarei Aerodrome about the airspeed indicator problem and asked him if he could have a look at it and blow out the pitot-static system. The engineer believed the call was made from the ground at about 1130, but he could not be certain of the time. The engineer agreed to rectify the problem and the pilot said he would arrive at the Aerodrome about noon. The engineer said he did not know that the pilot had spent the previous night in Whangarei or that the aircraft had been parked at the Aerodrome overnight. ZK-DZG was equipped with a global positioning system (GPS) and its navigation data was downloaded for analysis. From the data it was established that the aircraft departed from the airstrip at 1131 and flew for about 39 km on a track slightly right of the direct track to Whangarei Aerodrome, before altering heading direct to the aerodrome and Pukenui Forest located 5 km west of Whangarei city. A witness who had some aeroplane pilot flying experience, and was on a property close to the track of ZK-DZG, said he saw the aircraft fly past shortly after about 1130 at an estimated height of 500 feet. He watched it fly in the direction of Pukenui Forest for about 40 seconds before turning his head away. A short time later he turned again to look at the aircraft, which by then was just above the horizon about 2 ridges away. He said there was a strong, constant wind blowing from the right (south) of the aircraft, which appeared to be drifting sideways and rocking its wings. He then saw the aircraft enter a steep descending turn that seemed to tighten before it disappeared from view. He estimated it to have turned about 270 degrees. Another witness near the aircraft track and accident site reported seeing the aircraft at about 1140 flying just above the tree line and thought it might have been “dusting” the forest. The aircraft then turned and disappeared behind some trees. Other witnesses who heard or saw the aircraft described the weather as squally throughout the morning with strong winds from the south, and said that near the time of the accident there was no rain. The witnesses noticed nothing untoward with the aircraft itself, and at the time none was concerned that the aircraft may have been involved in an accident. The local aircraft engineer said he was not concerned when ZK-DZG did not arrive at Whangarei, because from his experience it was not unusual for agricultural pilots to change their plans at the last minute and to not inform the engineers. He described his conversation with the pilot as being casual and said the pilot did not mention that he was finishing topdressing for the day because of the weather. He thought the pilot was just trying to fit in the maintenance work and that his plans had changed. The pilot had not asked him to provide any search and rescue watch, nor did the engineer expect him to because he could not recall any pilot having asked him to do so. There was no evidence that the pilot made any radio calls during the flight. The frequency to which the radio was selected and its serviceability could not be determined because of the accident damage. At about 2200 a member of the pilot’s family contacted the emergency services when she became concerned that there had been no contact from the pilot. An extensive aerial search began at first light the next morning, and at about 1120 the wreckage of ZK-DZG was located about 50 metres (m) below a ridge in a heavily wooded area of Pukenui Forest, at an elevation of 920 feet above sea level. Both occupants were fatally injured.
Probable cause:
Findings are listed in order of development and not in order of priority.
- The pilot was correctly licensed, experienced and authorised for the flight.
- The pilot was operating the aircraft in an unserviceable condition because of a stuck airspeed indicator, which prevented him accurately assessing the aircraft airspeed. Consequently the
aircraft could have exceeded its airspeed limitations by some degree in the turbulent conditions.
- The structural integrity of the vertical fin had been reduced to such an extent by a cluster of unnoticed pre-existing fatigue cracks in its leading edge that eventual failure was inevitable. When the fin failed, it brought about an unrecoverable loss of control and the accident.
- Although the early design of the vertical fin met recognised requirements, it did not provide for any structural redundancy and the leading edge of the fin (a structural component) was not
damage-tolerant.
- The cracks in the fin leading edge went unnoticed until the failure, most likely because an approved black rubber anti-abrasion strip along that surface had prevented any detailed examination of it.
- The approved maintenance programmes did not reflect the inspection-dependent nature of the vertical fin for its ongoing airworthiness, with the inspection periods having been extended over
the years without full consideration given to the importance of frequent inspections for timely detection of fatigue damage.
- There was no evidence that the fitment of a more powerful STC-approved turbine engine, in place of a piston engine, had initiated the fatigue cracks in the fin leading edge. However, once
started, the extra engine power might have contributed to the rate of propagation of the cracks.
- The vertical fin defects and failures in the Fletcher aircraft over the years were not confined to turbine-powered aircraft.
- The CAA’s STC approval process for the turbine engine installation was generally robust and had followed recognised procedures, but the process should have been enhanced by an in-depth
evaluation of the fatigue effects on the empennage.
- Given the generally harsh operating environment and frequency of operations for the turbine powered Fletcher, the continued airworthiness requirements of the fin were not scrutinised as
robustly as they should have been during the STC approval process. Consequently the maintenance programmes had not been improved to ensure the ongoing structural integrity of the fin.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Mount Hotham: 3 killed

Date & Time: Jul 8, 2005 at 1725 LT
Operator:
Registration:
VH-OAO
Survivors:
No
Schedule:
Melbourne - Mount Hotham
MSN:
31-8252021
YOM:
1982
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4770
Captain / Total hours on type:
1269.00
Aircraft flight hours:
9137
Circumstances:
On 8 July 2005, the pilot of a Piper PA-31-350 Navajo Chieftain, registered VH-OAO, submitted a visual flight rules (VFR) flight plan for a charter flight from Essendon Airport to Mount Hotham, Victoria. On board the aircraft were the pilot and two passengers. At the time, the weather conditions in the area of Mount Hotham were extreme. While taxiing at Essendon, the pilot requested and was granted an amended airways clearance to Wangaratta, due to the adverse weather conditions at Mount Hotham. The aircraft departed Essendon at 1629 Eastern Standard Time. At 1647 the pilot changed his destination to Mount Hotham. At 1648, the pilot contacted Flightwatch and requested that the operator telephone the Mount Hotham Airport and advise an anticipated arrival time of approximately 1719. The airport manager, who was also an accredited meteorological observer, told the Flightwatch operator that in the existing weather conditions the aircraft would be unable to land. At 1714, the pilot reported to air traffic control that the aircraft was overhead Mount Hotham and requested a change of flight category from VFR to instrument flight rules (IFR) in order to conduct a Runway 29 Area Navigation, Global Navigation Satellite System (RWY 29 RNAV GNSS) approach via the initial approach fix HOTEA. At 1725 the pilot broadcast on the Mount Hotham Mandatory Broadcast Zone frequency that the aircraft was on final approach for RWY 29 and requested that the runway lights be switched on. No further transmissions were received from the aircraft. The wreckage of the aircraft was located by helicopter at 1030 on 11 July. The aircraft had flown into trees in a level attitude, slightly banked to the right. Initial impact with the ridge was at about 200 ft below the elevation of the Mount Hotham aerodrome. The aircraft had broken into several large sections and an intense fire had consumed most of the cabin. The occupants were fatally injured.
Probable cause:
Findings:
• There were no indications prior to, or during the flight, of problems with any aircraft systems that may have contributed to the circumstances of the occurrence.
• The pilot continued flight into forecast and known icing conditions in an aircraft not approved for flight in icing conditions.
• The global navigation satellite constellation was operating normally.
• The pilot did not comply with the requirements of the published instrument approach procedure.
• The pilot was known, by his Chief Pilot and others, to adopt non-standard approach procedures to establish his aircraft clear of cloud when adverse weather conditions existed at Mount Hotham.
• The pilot may have been experiencing self-imposed and external pressures to attempt a landing at Mount Hotham.
• Terrain features would have been difficult to identify due to a heavy layer of snow, poor visibility, low cloud, continuing heavy snowfall, drizzle, sleet and approaching end of daylight.
• The pilot’s attitude, operational and compliance practices had been of concern to some Airservices’ staff.
• The operator’s operational and compliance history was recorded by CASA as being of concern, and as a result CASA staff continued to monitor the operator. However, formal surveillance of the operator in the preceding two years had not identified any significant operational issues.
Significant factors:
• The weather conditions at the time of the occurrence were extreme.
• The extreme weather conditions were conducive to visual illusions associated with a flat light phenomenon.
• The pilot did not comply with the requirements of flight under either the instrument flight rules (IFR) or the visual flight rules (VFR).
• The pilot did not comply with the requirements of the published instrument approach procedure and flew the aircraft at an altitude that did not ensure terrain clearance.
• The aircraft accident was consistent with controlled flight into terrain.
Final Report: