Aviation safety investigations & reports

Beech Aircraft Corp 200, VH-SKC

Investigation number:
Status: Completed
Investigation completed


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On 4 September 2000, a Beech Super King Air 200 aircraft, VH-SKC, departed Perth, Western Australia at 1009 UTC on a charter flight to Leonora with one pilot and seven passengers on board. Until 1032 the operation of the aircraft and the communications with the pilot appeared normal. However, shortly after the aircraft had climbed through its assigned altitude, the pilot's speech became significantly impaired and he appeared unable to respond to ATS instructions. Open microphone transmissions over the next 8-minutes revealed the progressive deterioration of the pilot towards unconsciousness and the absence of any sounds of passenger activity in the aircraft. No human response of any kind was detected for the remainder of the flight. Five hours after taking off from Perth, the aircraft impacted the ground near Burketown, Queensland, and was destroyed. There were no survivors.

The investigation found that the pilot was correctly licensed, had received the required training, and that there was no evidence to suggest that he was other than medically fit for the flight. The weather presented no hazard to the operation of the aircraft on its planned route. The aircraft's flightpath was consistent with the aircraft being controlled by the autopilot with no human intervention after the aircraft passed position DEBRA. After the aircraft climbed above the assigned altitude of FL250, the speech and breathing patterns of the pilot displayed changes that were consistent with hypoxia, but a rapid or explosive aircraft cabin depressurisation was unlikely to have occurred.

Testing revealed that Carbon Monoxide and Hydrogen Cyanide were highly unlikely to have been factors in the occurrence, and the absence of irritation in the airways of the occupants indicated that a fire in the cabin was also unlikely. The possibility of the pilot alone being incapacitated by a medical condition such as a stroke or heart attack would appear unlikely, given that there was no apparent activity or action by the other occupants of the aircraft for the duration of the flight.

The investigation concluded that while there are several possible reasons for the pilot and passengers being incapacitated, the incapacitation was probably a result of hypobaric hypoxia due to the aircraft being fully or partially unpressurised and their not receiving supplemental oxygen. Due to the extensive nature of the damage to the aircraft caused by the impact with the ground, and because no recording systems were installed in the aircraft (nor were they required to be), the investigation could not determine the reason for the aircraft being unpressurised, or why the pilot and passengers did not receive supplemental oxygen.

However, the investigation concluded that an aural warning for high cabin altitude, and setting visual and aural alerts to operate when the cabin pressure altitude exceeds 10,000 ft, may have prevented the accident.

Download Final Report
[Download  PDF: 938KB]
General details
Date: 04 September 2000   Investigation status: Completed  
Time: 1510 hours UTC    
Location   (show map): 65 km ESE Burketown, (ALA)    
State: Queensland   Occurrence type: Air/pressurisation  
Release date: 07 March 2002   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Beech Aircraft Corp  
Aircraft model 200  
Aircraft registration VH-SKC  
Serial number BB-47  
Type of operation Charter  
Damage to aircraft Destroyed  
Departure point Perth, WA  
Departure time 1009 UTC  
Destination Leonora, WA  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command ATPL 138 2053
  Crew Passenger Ground Total
Fatal: 1 7 0 8
Total: 1 7 0 8
Last update 13 May 2014