Aviation safety investigations & reports

Douglas Aircraft Co Inc DC3C-S1C3G, VH-EDC, Botany Bay, NSW, 24 April 1994

Investigation number:
199401043
Status: Completed
Investigation completed

Summary

Download Final Report
[Download  PDF: 383KB]
 

Summary

On Sunday 24 April 1994, at about 0910 EST, Douglas DC-3 aircraft VH-EDC took off from runway 16 at Sydney (Kingsford-Smith) Airport. The crew reported an engine malfunction during the initial climb and subsequently ditched the aircraft into Botany Bay. The DC-3 was on a charter flight to convey a group of college students and their band equipment from Sydney to Norfolk Island and return as part of Anzac Day celebrations on the island. All 25 occupants, including the four crew, successfully evacuated the aircraft before it sank.

The investigation found that the circumstances of the accident were consistent with the left engine having suffered a substantial power loss when an inlet valve stuck in the open position. The inability of the handling pilot (co-pilot) to obtain optimum asymmetric performance from the aircraft was the culminating factor in a combination of local and organisational factors that led to this accident. Contributing factors included the overweight condition of the aircraft, an engine overhaul or maintenance error, non-adherence to operating procedures and lack of skill of the handling pilot.

Organisational factors relating to the company included:

  • inadequate communications between South Pacific Airmotive Pty Ltd who owned and operated the DC-3 and were based at Camden, NSW and the AOC holder, Groupair, who were based at Moorabbin, Vic.;
  • inadequate maintenance management;
  • poor operational procedures; and
  • inadequate training.

Organisational factors relating to the regulator included:

  • inadequate communications between Civil Aviation Authority offices, and between the Civil Aviation Authority and Groupair/South Pacific Airmotive;
  • poor operational and airworthiness control procedures;
  • inadequate control and monitoring of South Pacific Airmotive;
  • inadequate regulation; and
  • poor training of staff.

During the investigation, a number of interim safety recommendations were issued by the Bureau. These recommendations, and the CAA's responses to them, are included in this report.

Download Final Report
[Download  PDF: 383KB]
 
 
 
General details
Date: 24 April 1994   Investigation status: Completed  
Time: 0909 hours EST   Investigation phase:  
Location   (show map): Botany Bay   Investigation type: Occurrence Investigation  
State: New South Wales   Occurrence type: Navigation - Other  
Release date: 17 March 1996   Occurrence class: Operational  
Report status: Final   Occurrence category: Accident  
  Highest injury level: Serious  

Aircraft details

Aircraft details
Aircraft manufacturer Douglas Aircraft Company  
Aircraft model DC-3  
Aircraft registration VH-EDC  
Serial number 12874  
Type of operation Charter  
Damage to aircraft Substantial  
Departure point Sydney, NSW  
Departure time 0907 hours EST  
Destination Botany Bay, NSW  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command ATPL 927 9186
Co-Pilot/1st Officer Commercial 250 500
 
Injuries
  Crew Passenger Ground Total
Serious: 1 0 0 1
Minor: 3 1 0 4
Total: 4 1 0 5
Last update 13 May 2014