Aviation safety investigations & reports

Beech Aircraft Corp A23A, VH-BZO

Investigation number:
Status: Completed
Investigation completed


The Beech Musketeer aircraft was being operated on a private pleasure flight. On board were the pilot and three passengers.

The aircraft took off from runway 30 and began climbing at a shallow angle, which a witness reported was below the normal climb profile. When the aircraft reached a point about 100 m beyond the upwind threshold of the runway, the tower controller informed the pilot of inbound traffic directly ahead of the aircraft. At that time, the tower controller also noticed that the aircraft was exhibiting `wobbles' and became concerned for its safety. Witnesses reported that the aircraft slowly climbed to about 300 ft and then seemed to lose altitude. The aircraft then continued tracking outbound in a shallow climb on runway heading, before the right wing dropped. The aircraft then rolled to the right, assumed a steep nose-down attitude and began rotating. After one turn, the aircraft impacted the ground in a steep nose-down inverted attitude. A fireball engulfed the aircraft immediately after impact. The four occupants received fatal injuries.

The accident site was located in an open paddock covered with dry grass, about 1.3 km from the upwind threshold of runway 30 and about 200 m left of the extended centreline. The wreckage was contained within an area about 30 m by 20 m, consistent with the nature of the impact. However before being extinguished, the post-impact fire burned out an area about 130 m by 80 m.

Factual Information

Wreckage examination

The airframe had come to rest in an upright attitude, aligned about 250 degrees M, about 12 m north of the initial impact point. The wings, fuselage and empennage were in the normal places relative to each other. The fuselage had been destroyed by impact forces and post-impact fire. The wings displayed extensive post-impact fire damage. The empennage was relatively intact but had suffered some post-impact fire damage.

The engine had separated and come to rest inverted about 3 m west of the airframe and about 10 m north of the initial impact point. The axis of the engine was perpendicular to the axis of the airframe. The lower engine mount brackets had been severed and the engine mounts deformed, indicating an impact from the left side. The propeller had separated from the engine when the engine shaft failed due to excessive bending and torsion, and was buried 15 cm below the surface about 1 m from the initial impact point. Inspection of the propeller revealed one blade bent in the chordwise direction with the tip 14 cm aft of the normal position, indicating that it was developing power at the time of impact.

The flight control surfaces did not show any witness marks to indicate their pre-impact positions. The flight controls were cable operated and were found to be correctly and securely attached to their respective control surfaces. However, some cables had been torn off at the controls in the cockpit area. The flap extension lever was found in the stowed position. There was no evidence of the locking tongue having been forced over the slots. This indicated that the flaps had been retracted before impact.

The fuel system and components showed various degrees of fire damage. The remains of the fuel lines were in the expected locations and remained securely attached to their respective components. Both fuel caps were found mounted in the fuel filler ports and with their locking mechanisms closed. The examination of the fuel system did not reveal any pre-impact defect that would have prevented normal operation of the system. The extent of the fire attested to a significant fuel load on board.

Due to the intensity of the fire, no fuel remained in the wreckage. Two sets of fuel samples were taken from tank number four at Canberra Airport. The samples were assessed and found to be consistent in colour and appearance with 100LL Avgas, of normal density, and free from water. Several aircraft had refuelled from the same bowser earlier in the day. None of the pilots of those aircraft reported any fuel-related problems.

The engine was removed and stripped for inspection. The examination did not reveal any pre-impact defect that would have prevented the engine from operating normally.


The pilot held a Private Pilot Licence (Aeroplane) and was endorsed for single-engine aircraft below 5,700 kg maximum takeoff weight (MTOW). He was 34 years of age and held a current Class 2 medical certificate with no special requirements.

The pilot had obtained his licence on 7 April 2000 and reportedly had accrued less than 100 hours flying experience. A precise figure could not be obtained as the pilot's logbook, which was recovered from the aircraft wreckage, had been almost destroyed by fire.

The pilot had begun his flying training some time previously, but the completion of his Private Pilot training was delayed. He subsequently completed his Private Pilot training with a Canberra-based flying training and charter operator. At the time of the accident, the pilot was purchasing both the Musketeer and the training and charter company. Between 5 January 2000 and 23 April 2000, the pilot completed 25 training flights, totalling 30.9 hours, of which 25.8 hours were dual and 5.1 hours were solo. The pilot passed his General Flying Proficiency Test on 7 April 2000 and subsequently completed eight navigation training flights totalling 16.9 hours dual and 5.0 hours solo.

An instructor assessed the pilot's flying skills as sound, but added that the pilot tended to be over-confident. Another instructor said that although the pilot's aircraft handling met the required standard, he tended to be casual and to chat during flight. He added that the pilot did not always concentrate sufficiently on the task in hand, and did not always prepare fully for cross-country flights.

A witness said that all four aircraft occupants had arrived at the pilot's home in Canberra, after driving from Brisbane in two vehicles, in the early hours of the morning on the day of the accident. En route, they had visited a private home at Umina on the NSW Central Coast, departing there at about 2130 hours Eastern Standard Time (EST), and had probably arrived in Canberra about 0130. The witness observed the pilot up and about at 0630 EST on the day of the accident.

Neither the autopsy nor the toxicology reports on the pilot revealed any medical condition that would have impaired his ability to operate the aircraft.


The weather conditions at the time of the accident were:

Surface wind: 035/04-06 kts (Max headwind component 0.5 kt, max crosswind component 6 kt)
Visibility: 40 km
Temperature: 25.3 degrees C
Dew point: 12.5 degrees C
QNH: 1014.0 hPa
Cloud: 2 octas cumulus, base 5,000 ft

These conditions produced a density altitude of 3,400 ft on the ground at the aerodrome. The aerodrome elevation is 1,888 ft above mean sea level (AMSL).

Aircraft weight and balance

Based on a fuel load of 115 L and weights of the aircraft occupants as determined by the autopsies, the aircraft gross weight at takeoff was calculated as 2,375 lb. The maximum permitted gross weight for takeoff was 2,400 lb. The aircraft centre of gravity was near the middle of the permitted range.

Aircraft performance

According to performance charts, the aircraft was capable of takeoff and climb from runway 30 with 15 degrees of flap selected, and climb at maximum gross weight under the prevailing environmental conditions. However, with a density altitude of 3,400 ft and the aircraft gross weight just below MTOW, the pilot would have needed to monitor take-off and climb performance closely.

Stall warning system

The aircraft was equipped with the normal stall-warning system: a vane mounted in the wing leading edge that moved upward, triggering an aural warning, when the wing's angle of attack approached the stalling angle.

Before departing on the aircraft's delivery flight to Canberra 14 days before the accident, the pilot who carried out the delivery flight tested the system on the ground and found it to operate when the vane was raised manually. The day following the delivery flight, the accident pilot carried out a flight carrying three passengers, one of whom reported that the warning system had operated briefly a couple of times on that flight.

Another pilot who had flown the aircraft on two occasions said that during the flare prior to touchdown, the aircraft had stalled and firmly contacted the ground. On neither occasion did he remember hearing the stall warning operate.

The serviceability of the stall-warning system on the day of the accident could not be determined due to impact and fire damage.

Possible effects of terrain

The 570 m (1,880 ft) elevation contour line passes through the middle of the aerodrome but higher terrain lies to the west, north-west and north. Along the extended runway centreline, the terrain rises to 630 m (2,060 ft). To the left and right of the extended centreline the terrain rises to 662 m (2,170 ft) and 840 m (2,760 ft) respectively.

Visual illusions can occur in flying and result from a pilot's incorrect interpretation of what is seen. A pilot's susceptibility to visual illusions will depend largely on the amount and nature of his/her flying experience, although other factors such as fatigue tend to increase susceptibility.

When flying visually, a pilot judges the aircraft's attitude by the relationship between the nose of the aircraft and the horizon. This is then crosschecked with the aircraft instruments to confirm the aircraft is performing as expected. The various phases of visual flying such as climbing, descending and turning are accomplished by adjusting engine power and aircraft attitude. However, a pilot also receives indications of attitude and performance from his/her senses which can be deceptive.

Gently rising terrain ahead of a low-flying aircraft can lead a pilot flying visually to misjudge the horizon, thinking that it is higher than its true position. If the pilot uses this false horizon as a pitch-attitude reference, the aircraft nose attitude will be higher than normal, resulting in a reduction in airspeed. If a pilot does not monitor the airspeed closely, or does not apply power to compensate for the steeper angle, the aircraft can slow, unnoticed, to its stall speed.

Rising terrain can also mislead a pilot into believing that the aircraft is not climbing at the required rate. If the pilot then selects a higher nose attitude without reference to performance instruments, and does not apply additional power, the airspeed will reduce.

The maximum altitude attained was about 300 ft above the aerodrome elevation. The accident site was located at the base of rising terrain. Looking directly ahead, the pilot would have observed terrain rising to an elevation slightly below the altitude at which the aircraft stalled. Either side of the aircraft's heading, the terrain was higher still. Although it cannot be confirmed, the pilot might have been misled by the rising terrain and raised the aircraft's nose above the normal climb attitude.

Possible distractions

As the aircraft was taxiing for takeoff, the Surface Movement Controller (SMC) transmitted the Musketeer's airways clearance to the pilot, which he read back confidently and correctly. Twenty-six seconds later, the SMC heard about 30 seconds of open microphone transmission, indicating that the transmitting station was experiencing problems with an aircraft seat. The SMC then called the transmitting station, informing it that its intercom was being transmitted on SMC frequency. Although the source of the transmissions could not be confirmed, the indications pointed to the Musketeer. Exactly 2 minutes later, the Aerodrome Controller (ADC) gave the Musketeer its takeoff clearance; in his readback, the pilot sounded unsure of himself and made a couple of errors.

As the aircraft was climbing after takeoff, the ADC passed traffic information to the pilot, informing him of an inbound helicopter in his 12 o'clock. The pilot acknowledged and replied that he was looking for traffic. That was the last radio transmission from the aircraft; about 30 seconds later, the aircraft impacted the ground.



The density altitude of 3,400 ft and the aircraft's gross weight (just below the maximum permitted) combined to adversely affect the aircraft's acceleration and climb performance. This was evident from the witness reports stating that the aircraft's angle of climb seemed to be shallower than normal for single-engine light aircraft departing on runway 30. The brief loss of altitude before the right wing dropped was probably the result of the pilot raising the flaps.

As the aircraft was lower than the normal climb profile, rising terrain ahead might have affected the pilot's assessment of the aircraft's nose attitude with respect to the horizon or its rate of climb with respect to terrain, leading him to select a higher nose attitude than he would have selected otherwise.


Although precise figures for the pilot's total experience and his experience on type could not be determined, he was known to be relatively inexperienced. However, he had completed several previous flights in the Musketeer, including at least two flights with a passenger in a rear seat.

The four aircraft occupants had arrived back in Canberra at about 0130 on the day of the accident after driving in two vehicles from Brisbane. The pilot had risen by 0630. He could not have had more than 5 hours sleep in bed after arriving home. However, it cannot be assumed that he did all the driving; the other vehicle occupant might have driven the final trip from Umina to Canberra, permitting the pilot to obtain some sleep during that time.

Although it could not be confirmed that the Musketeer was the source of the open microphone transmissions on SMC frequency, some of the phraseology heard at the time supported this conclusion. In the event, the pilot might have had his confidence shaken, resulting in the errors in his readback of his take-off clearance.

After receiving the traffic information about the inbound helicopter directly ahead, the pilot may have been devoting considerable attention to looking for the helicopter, allowing his concentration on flying the aircraft to lapse.

The reason for the stall could not be established.

Stall warning system

Although it could not be confirmed, it is possible that the stall warning system did not operate, thus denying to the pilot the aural warning of an approaching stall.

Significant Factors

  1. The aircraft stalled at an altitude from which a recovery was not effected.
General details
Date: 28 January 2001   Investigation status: Completed  
Time: 1230 hours ESuT    
Location   (show map): 1.3 km NW Canberra, Aero.    
State: Australian Capital Territory   Occurrence type: Collision with terrain  
Release date: 12 October 2001   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Beech Aircraft Corp  
Aircraft model 23  
Aircraft registration VH-BZO  
Serial number M-1075  
Type of operation Private  
Damage to aircraft Destroyed  
Departure point Canberra, ACT  
Departure time 1222 hours ESuT  
Destination Khancoban, NSW  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command Private 100
  Crew Passenger Ground Total
Fatal: 1 3 0 4
Total: 1 3 0 4
Last update 13 May 2014