History of the flight
The pilot of a Cessna C206 was conducting a charter flight in accordance with the visual flight rules (VFR) from Margaret Bay to Cairns with a passenger and a cargo of live seafood. The flight was reported to have departed Margaret Bay at 1520 EST. At 1719 the Brisbane Daintree sector controller broadcast, on the area frequency, the amended Cairns terminal area forecast and the trend type forecast that indicated visual meteorological conditions (VMC) did not exist. Six minutes later, when the aircraft was estimated to have been northwest of Cooktown, the pilot requested the weather conditions at Mareeba. The controller informed the pilot of the automatic weather observing system information for Mareeba and said that he would attempt to obtain a cloud cover report from an overflying aircraft. The pilot was not informed of that information nor did he subsequently request it. At 1813 he reported at Cape Tribulation, 51 NM north of Cairns, and revised his estimate for Cairns to 1838. That estimate was 10 minutes after last light for Cairns. Shortly after, a pilot on the airstrip at Wonga Beach, about 38 NM north of Cairns, sighted the lights of an aircraft tracking coastal toward Cairns. That observer estimated that the aircraft was flying at an altitude of 100 ft and in visibility reduced to less than 1 NM in heavy rain and approaching darkness.
At 1824, four minutes before last light, the pilot contacted Cairns approach and reported that the aircraft was 33 NM north of Cairns. After the pilot confirmed that his operations were normal the approach controller advised him of the aerodrome terminal information service (ATIS) weather at Cairns. The controller asked the pilot if he was able to remain in sight of the coast and if he was capable of flight in instrument meteorological conditions (IMC). The pilot advised that he had the coast in sight and that he was not capable of flight in IMC. The controller subsequently issued the pilot with a clearance to follow the coast not above 1,000 ft and remain in VMC. Although the pilot had not declared an emergency, the controller recognised the potential danger and declared an uncertainty phase.
Radar data from the time the aircraft was identified north of Cairns showed that the aircraft tracked east of the coast at altitudes varying between 200 and 600 ft. During that time the approach controller provided the pilot with cloud and visibility information reported by pilots conducting instrument approaches to runway 15 at Cairns. He monitored the progress of the flight and provided the pilot with distance and groundspeed information. He also offered the pilot radar headings to establish the aircraft clear of terrain and position the aircraft for an approach to runway 15. The approach controller requested that the aerodrome controller select the approach lighting to maximum illumination. The pilot, in response to a query by the approach controller, advised that he had his landing lights on during the approach.
The Cairns meteorological observation at 1830 recorded a visibility of 2,500 m in rain showers with scattered stratus cloud at 300 ft and broken cumulus at 1,800 ft. A pilot making an instrument approach to Cairns ahead of the C206 reported the main cloud base as 1,100 ft with lower patches of cloud. He reported seeing the approach lights at 4 NM and the runway lights at 1 NM. The aerodrome controller estimated that the visibility at the time the C206 was making its approach was 1,500 m in heavy rain.
When the C206 was almost overhead the airport the pilot reported that he was unable to see the runway lights, so the controller instructed him to make a left orbit for a second landing attempt. The aerodrome controller saw the aircraft descend from 400 ft to approximately 100 ft during the turn and activated the crash alarm because he thought an accident was imminent. He selected omni-directional runway lighting to aid detection. The pilot's second approach was also unsuccessful and again the aircraft was seen to lose altitude while turning left. The approach controller then directed the pilot to take up a northerly heading, away from obstacles and terrain. He intended to position the aircraft for a third approach along the extended runway centre line so that the pilot would be better positioned to use the approach lighting for guidance to the runway. That flight path took the aircraft over the water off Machans Beach. At 1851, on the third attempt to approach and land and while being radar vectored onto a left base leg to runway 15, the aircraft disappeared from radar 2 NM north-north-east of Cairns.
Witnesses at Machans Beach reported seeing the lights of an aircraft flying at low-level offshore. They described seeing the lights rotate in a manner consistent with the aircraft rolling steeply to the left and disappearing from view in rain and mist. One witness reported hearing a faint sound of impact. Airport rescue and firefighting services had been alerted nearly one minute before the aircraft disappeared from radar. Despite the inclement conditions, an air and sea search of the area was conducted by the Cairns based search and rescue helicopter and rescue craft from the airport rescue and firefighting service. At 2050, searchers found the body of the passenger and debris in the water near the reported accident site. The following day some personal items and debris from the aircraft were found. Damage to the recovered aircraft parts suggested that the aircraft had impacted the water heavily and the accident was not survivable.
Air, sea and coastal searches continued over the next few days, including the use of airborne electronic detection equipment, but neither the pilot nor the main aircraft wreckage was found. On 9 November, 3 months after the accident, wreckage was sighted approximately 4 km offshore. Divers recovered parts from the underwater wreckage that were later identified as belonging to the accident aircraft.
The company was contracted to fly cargoes of live seafood, reported to be valued at up to $18,000 per flight, from Margaret Bay to Cairns. On the day of the accident, two company aircraft were scheduled to make the flight. Those flights were normally flown by instrument rated pilots. Regulations allowed cargo flights in single engine aircraft to be conducted in accordance with instrument flight rules (IFR) and at night. That allowed greater planning flexibility when tide levels dictated later departure times from Margaret Bay. Although both aircraft were equipped for flight in accordance with IFR only one had an autopilot. A serviceable autopilot was a requirement for single-pilot IFR. As only one instrument rated pilot was available it was decided that he should fly the auto-pilot equipped aircraft while the accident pilot flew the C206.
Careful planning was necessary to ensure that the aircraft piloted by the non-instrument rated pilot could conduct the flight in accordance with VFR. Flights to Margaret Bay were planned to arrive and depart during periods when tide levels below 1.8 m permitted use of the beach as a landing area. On the day of the accident there were two periods when tide levels were less than 1.8 m, one early to mid morning and the other from 1340 that afternoon. The earlier period was considered impractical. A first light departure from Cairns would not have allowed an arrival at Margaret Bay early enough to complete a normal turnaround on the beach before the advancing tide. The customer also preferred the later arrival time which just made possible a normal turnaround and return flight to Cairns in daylight. The pilot had determined 1500 as the latest time he could safely depart Margaret Bay for an arrival at Cairns before last light.
Boat crewmembers were sometimes transported to Margaret Bay on the flights. Regulations governing the carriage of passengers in single, reciprocating-engine aircraft required the flights to be conducted in accordance with day VFR. On 3 August a passenger was to be flown to Margaret Bay. Additionally, the customer requested that an injured deck hand on the boat be flown to Lockhart River while the transfer of cargo from the boat to the beach was being carried out. The deck hand had severed the tip of a finger the previous day. Although not requiring urgent medical attention he was anxious to get to hospital where it was reported that arrangements had been made to have the severed part of his finger sewn back. Overnight accommodation at Lockhart River had been arranged for the injured deck hand and a reservation made for him on the next day's scheduled flight to Cairns. The aircraft operator advised that the flight was not possible because the additional flying time to Lockhart River and return would not have ensured arrival back at Cairns before last light. Instead the operator and the customer agreed to limit the volume of cargo in the C206 and fly the passenger direct to Cairns.
Delayed departure from Margaret Bay
Arrival of the aircraft was signalled to the crew of the fishing boat by circling overhead. When alerted, the crew commenced packing the live seafood into tubs in preparation for air transport to Cairns. Loading and transfer from the boat to the aircraft took longer than normal. Witnesses reported that the pilot appeared to be extremely agitated and was visibly distressed about the delay but he had expressed the belief that more favourable winds at a higher altitude might enable him to make up the lost time. The pilot of another VFR aircraft on the beach at that time reported that he estimated there was inadequate daylight for his return to Cairns with the existing wind conditions and elected to remain overnight. He had suggested the same course of action to the accident pilot but reported that the accident pilot had made up his mind to return to Cairns that day. Logistically, a landing at Cooktown would have taken surface transport over eight hours for the return journey from Cairns. The consequences of that action would have delayed treatment to the injured passenger and risked the loss of the perishable cargo.
The pilot held a commercial pilot licence and a valid Class 1 medical certificate. He had accumulated 13,157 hours flight experience during 22 years of active employment in general aviation. Most of his flying experience was flight instruction and he held a current Grade 1 Instructor Rating. In 1991 he qualified for a Command Instrument Rating endorsed for non-directional beacon (NDB) approaches only. He had not renewed the rating after its expiry on 30 April 1993. The only recent instrument flight the pilot recorded were practice NDB approaches on a synthetic procedure trainer in preparation for revalidation of his lapsed instrument rating. In the 90 days prior to the accident he had logged 6.6 hours of night flying that included a navigation training flight and a check flight with the Chief Pilot.
During the 12 months preceding the accident the pilot had recorded 515 hours of which 35 hours were charter flying. Nearly all of that charter flying consisted of short local scenic and aerial work flights. Although the pilot had not flown to Margaret Bay for some time, he was familiar with the York Peninsula area. The 72-hour history of the pilot did not reveal any circumstances that would have affected his ability to perform his duties. The family of the pilot reported that he was unusually anxious about undertaking the flight and had expressed concern about the available time frame for the flight. The chief pilot, who was responsible for rostering pilots, described the pilot as reliable and possessing sound judgement. He described the pilot's decision to continue the flight in darkness and poor weather as uncharacteristic.
Aircraft and equipment
It was not possible to determine if there was any aircraft defect that may have contributed to the accident sequence. Examination of the small amount of wreckage that was recovered indicated that the aircraft engine was developing some power at the time of impact. Inspection of the aircraft's maintenance documentation showed that the required maintenance had been certified as completed. Pilots who flew the aircraft before the accident flight reported that it had been serviceable. The aircraft was certified for flight in accordance with the instrument flight rules (IFR). An entry on the duplicate copy of the maintenance release stated that there was no autopilot fitted and that for IFR operation in accordance with Civil Aviation Order (CAO) 20.18 subsection 4.1B (ie, Charter or Airwork), two instrument rated pilots were required. The duplicate copy of the maintenance release also noted that no Emergency Locator Transmitter (ELT) was installed. The aircraft was equipped with a VHF omni-directional radio range (VOR) receiver, incorporating glideslope information that enabled instrument landing system (ILS) approaches to be flown and automatic direction finding (ADF) radio navigation aids. The pilot had borrowed a portable hand-held Global Positioning System (GPS) satellite navigation unit for the flight and had mounted it on top of the instrument panel. The unit also displayed tracking and groundspeed information.
The forecast obtained by the pilot that morning indicated that VMC could be expected along the planned route but with visibility reduced to 2,000 m in isolated areas of drizzle, showers and smoke. The Cairns terminal area forecast (TAF) issued at 0825 forecast VMC with showers of rain but no further deterioration until 2000; well after the planned arrival at Cairns. At 1328 the Cairns TAF was amended to include an intermittent (INTER) deterioration in conditions below VMC from 1600. An INTER is used to indicate changes expected to occur frequently for periods of less than 30 minutes duration, with conditions fluctuating almost constantly, between the times specified in the forecast. The amended Cairns TAF also included a temporary (TEMPO) deterioration in conditions from 2000. TEMPO is used to indicate changes in prevailing conditions expected to last for a period of less than one hour in each instance. A further amendment to the Cairns TAF was issued at 1531 that forecast a visibility reduced to 9,000 m in showers and patches of low cloud with a base of 800 ft. A TEMPO period from 1800 forecast visibility reduced to 2,000 m in showers with patches of low cloud at 300 ft. This was the forecast broadcast by the controller at 1719, while the aircraft was estimated to be north-west of Cooktown.
Recorded rainfall data indicated that rainfall intensity at Cairns airport for that day was greatest between 1800 and 1900.
The Aeronautical Information Publication stated that day VFR flights must not depart from an aerodrome unless the Estimated Time of Arrival (ETA) for the destination or alternate is at least 10 minutes before last light, after allowing for any required holding. Calculations based on aircraft performance and forecast winds gave a planned time interval of 3 hours 15 minutes. That meant that a departure from Margaret Bay at 1520 would result in an ETA for Cairns of 1835, seven minutes after last light. The amended Cairns TAF with the INTER requirement, broadcast by the controller at 1719, would have necessitated an arrival at Cairns no later than 1748 in order to meet the requirements for VFR flight. Pilots of VFR aircraft faced with similar circumstances were taught, as part of their training, to make an in-flight diversion to another destination while weather and daylight permitted. Weather conditions at Cooktown that afternoon were reported to be VMC.
Operational control was defined as the exercise of authority over the initiation, continuation, termination or diversion of a flight, in the interest of the safety of an aircraft.
Prior to January 1992 the then Civil Aviation Authority through its specialist air traffic services personnel provided a comprehensive operational control service. Pilots of VFR flights proceeding more than 50 NM were required to submit flight plan information that was checked by controllers to ensure compliance with regulations and operational requirements. Operations controllers with access to current weather and NOTAM information monitored all flights to ensure that pilots were aware of significant changes to weather and other operational factors that may affect the safety of the flight. That information was transmitted through the aeronautical communications network to a pilot and, when considered necessary, an appropriate response sought. In extreme cases, pilots could be directed to land or be diverted to ensure the safety of the flight.
Following a review of that service, changes to Australian regulations were made to more closely align with international regulations. Those changes resulted in the withdrawal of the operational control service and greater responsibility for the safe conduct of a flight to the pilot in command. In effect that meant that operational control was exercised by a pilot complying with regulations, standard operating procedures as published in company Operations Manuals and by displaying sound airmanship.
The Civil Aviation Safety Authority (CASA), in its program of regulatory reform, intends to require air transport (incorporating what is currently termed charter) operators to establish and maintain a method of supervision of operations. If accepted, the changes would require operators to state in their Operations Manual the means by which operational control is to be exercised. It is envisioned that such regulation would cover at least a description of responsibilities concerning the initiation, continuation, termination or diversion of each flight and include specific information to pilots on suitable alternate aerodromes and the means of updating weather and NOTAM information.
In the manual "Aeronautical Decision Making for Commercial Pilots" developed for the United States Federal Aviation Administration (FAA), the point is made that charter pilots often have to balance commercial considerations against safety and compliance with regulations. In doing so they can be subjected to pressures from management, clients and passengers more attuned to non-safety related issues such as economy and expediency. Those people may assume that the pilot will resist these pressures if there is any "real" danger and respond appropriately to avoid disaster. Conversely, pilots can be persuaded, even to the detriment of safety, by the knowledge that a decision contrary to the wishes of the customer or management may incur economic penalties that could adversely affect commercial viability and hence their employment. Pilots who regularly fly in such environments become used to recognising those conflicting demands and practicing their decision-making skills.
The importance of good pilot decision-making skills was recognised by the Civil Aviation Safety Authority. In 1996 decision-making as a topic was included in the Human Performance and Limitations section of the Day VFR Syllabus (Aeroplanes) of the Aeronautical Knowledge requirements for pilots. The requirements included a knowledge of the basic concepts of decision making including the influence of employer pressure, the desire to get the task done, workload management, work overload and currency. That knowledge requirement was not made retrospective. Transport Canada introduced a similar requirement for commercial pilots engaged in multi-crew operations to complete a "once only" pilot decision-making course. Following an accident in 1998 involving a high-performance single-engine turbine aircraft, the Canadian Transportation Safety Board recommended that the requirement be extended to all pilots engaged in commercial operations.
Identifying hazards and developing contingency plans to avoid or mitigate their effect is a risk management strategy used by safety-conscious individuals or organisations to reduce risk. The transport of perishable cargo from a remote beach landing site presented additional hazards to that of normal charter operations. The company had addressed the hazards associated with landing and taking off from beaches by determining tide heights that permitted adequate runway width and by additional beach take-off and landing training for pilots. Flights made under the IFR were not as likely to be delayed or diverted and reduced the risk of losing valuable cargoes because of the perishable nature of the live seafood. However, use of VFR aircraft and pilots increased the possibility of weather or daylight affecting an assured arrival.
The VFR pilot of the other aircraft engaged in the transport of live seafood from Margaret Bay to Cairns had identified risks associated with his operation and taken precautions to avoid them. He had fitted a marine high frequency channel to his aircraft's radio to permit direct communication with the fishing boat crew. That enabled him to advise them of his arrival so that they could prepare for the transfer of cargo and avoid delay. He also forewarned the crew of his latest time of departure of 1445 and his alternative arrangements for an overnight stay should the deadline not be met. Importantly, when the boat crew failed to meet the deadline he implemented his contingency plan and flew to a nearby island where he remained overnight, returning the next day as arranged, to collect the cargo and fly it to Cairns. That was the course of action he had suggested to the pilot of the C206 on the beach at Margaret Bay.
The Civil Aviation Safety Authority, in a discussion paper issued in May 2000, proposed changes for certification of commercial air transport operators (incorporating charter) that included an obligation for those operators to introduce an accident prevention and flight safety program incorporating risk management processes and hazard identification.
Planning for the flight had ensured compliance with the regulations but provided little or no margin for any delay or poor weather. Despite the narrow margins, there was no evidence of any contingency planning. Although primary responsibility for the safety of the flight rested with the pilot, lack of additional guidance or alternative arrangements, did not provide an opportunity to influence the pilot's subsequent actions. In this instance the pilot considered diverting to Mareeba but, because that did not offer a better alternative, he continued flying toward Cairns rather than landing at Cooktown. It is possible that concerns for the injured passenger and the perishable cargo may have influenced the pilot's judgement and in-flight decision making.
Lack of recent exposure to that type of charter flying may have also affected the judgement and decision-making skills displayed by the pilot. The type of operational decision-making required of a charter pilot was significantly different from the type of decisions required during instructional duties and may have accounted for the pilot's expressed anxiety about undertaking the flight. It could also account for the chief pilot's assessment of the pilot's decision-making ability being inconsistent with that displayed on that occasion.
The pilot's decision to depart Margaret Bay approximately 20 minutes later than the planned latest time of departure was based on his assumption that more favourable winds at a higher altitude might allow an arrival at Cairns before last light. That decision was significant to the development of the accident sequence. The 1520 departure from Margaret Bay meant that the planned flight would arrive at Cairns seven minutes after last light. The GPS navigation unit could have provided the pilot with an estimate for Cairns that would have confirmed that a landing at Cairns before last light was unlikely. The pilot's decision to continue, especially after he received advice that weather conditions at Cairns had deteriorated below VMC, was even more crucial to the outcome. Continued flight in darkness and non-VMC weather conditions ultimately created the circumstances conducive to the accident.
The pilot elected to remain at low-level, below the cloud and in sight of the coast. Although the pilot had previously held an instrument rating, he was not trained to fly an ILS approach. He did not have any recent instrument flight time and probably lacked the confidence to climb the aircraft into cloud and to a safe altitude above terrain. Tracking visually along the coast resulted in a flight path that was not aligned with the extended runway centre line and denied the pilot the opportunity of using approach lighting, in the reduced visibility, for guidance to the runway. Light reflected from the aircraft's landing light beam in the rain and mist may have also prevented the pilot from seeing the runway lights during the unsuccessful approach attempts.
Anxiety produced by the delayed departure, deteriorating weather conditions and darkness, would have combined to increase the pilot's level of stress. The likelihood of fatigue affecting the pilot's cognitive and motor skills due to the mental and physical demands of flying the aircraft, especially in the latter stages of the flight, may have been considerably increased. High stress levels, fatigue and lack of external visual reference most likely contributed to the pilot experiencing spatial disorientation and subsequent loss of control.
The circumstances of the accident were consistent with the pilot experiencing spatial disorientation and subsequent loss of control while manoeuvring the aircraft in darkness and poor weather without adequate visual cues.
- The pilot departed Margaret Bay later than planned without the certainty that the flight could be completed in the required daylight conditions.
- The pilot continued flight in weather conditions for which he was not currently qualified.
- The pilot continued flight in weather conditions for which the aircraft was not adequately equipped.
- The pilot, after receiving radar navigation assistance, was unable to see the runway lights.
- The pilot possibly experienced spatial disorientation and loss of control while manoeuvring the aircraft in darkness and poor weather without adequate visual cues.
|Date:||03 August 2000||Investigation status:||Completed|
|Time:||1851 hours EST|
|Location:||4 km NNE Cairns, Aero.|
|State:||Queensland||Occurrence type:||VFR into IMC|
|Release date:||20 December 2001||Occurrence category:||Accident|
|Report status:||Final||Highest injury level:||Fatal|
|Aircraft manufacturer||Cessna Aircraft Company|
|Type of operation||Charter|
|Damage to aircraft||Destroyed|
|Departure point||Margaret Bay, QLD|
|Departure time||1520 hours EST|
|Role||Class of licence||Hours on type||Hours total|