Aviation safety investigations & reports

Piper Aircraft Corp PA-32-300, VH-MAR

Investigation number:
Status: Completed
Investigation completed


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At about 1708 Eastern Standard Time (EST) on 26 September 2002, the pilot of a Piper PA-32-300 (Cherokee Six) aircraft, registered VH-MAR, reported taxiing for departure from runway 14 at Hamilton Island, Queensland. The charter flight was to Lindeman Island, a distance of about 15 km to the southeast. On board the aircraft were the pilot and five passengers.

Witnesses to the east of runway 14 at Hamilton Island reported that, shortly after the aircraft became airborne, the engine began coughing and misfiring, before cutting out and then starting again. Shortly after, the aircraft commenced a right turn, and the engine was heard spluttering and misfiring. Witnesses reported that, when part way around the turn, the engine again cut out, and the aircraft descended and impacted the ground.

The aircraft came to rest upright, aligned in an east-north-easterly direction, approximately 300 m to the west of the runway centreline and approximately 100 m south of the departure end of the runway. A severe post-impact fire consumed the majority of the aircrafts fuselage. The six occupants of the aircraft were fatally injured.

The pilot was qualified, appropriately endorsed and authorised for the operation. The pilots condition and demeanour on the day of the occurrence were reported to be normal.

There was no evidence that fuel contamination, amount of fuel carried, structural failure or meteorological conditions were factors in the occurrence.

The engine installed in the aircraft was different from that specified in the aircraft Type Certificate Data Sheet. Notwithstanding, the Civil Aviation Safety Authority (CASA) and the engine manufacturer reported that the installed engine should have been capable of producing the power output expected from the engine certified for installation in the Cherokee Six. Furthermore, the engine had been in service in the aircraft for 126.2 flight hours with no reported power abnormalities, suggesting that, provided there were no defects, the engine should have been capable of producing the required power throughout its operating range.

The extensive damage caused by the impact forces and post-impact fire prevented functional testing of a significant number of aircraft and engine components. On the available evidence, there was nothing found to suggest what may have degraded the engine performance to the extent reported by the witnesses to the occurrence.

Post-mortem toxicological examination of the pilots blood revealed a blood alcohol concentration (BAC) of 0.081%, the presence of an inactive metabolite of cannabis, and an analgesic preparation consistent with a therapeutic dosage. The possibility that the pilots BAC reading resulted at least in part from post-mortem alcohol production could not be discounted.

There was insufficient evidence to definitively link the pilots prior intake of alcohol and/or cannabis with the occurrence. However, the adverse effects on pilot performance of post-alcohol impairment, recent cannabis use and fatigue could not be discounted as contributory factors to the occurrence. In particular, the possibility that the pilot experienced some degree of spatial disorientation during the turn as a combined result of the manoeuvre, associated head movements and alcohol-induced balance dysfunction could not be discounted.

The following factors were considered to have significantly contributed to the occurrence.

  1. Based on witness reports, the aircrafts engine commenced to operate abnormally shortly after lift off from the runway.
  2. The pilot initiated a steepening right turn at low level.
  3. The aircraft stalled at a height from which the pilot was unable to effect recovery.

The operator has initiated a number of safety actions in order to mitigate some of the issues identified in the report. Those actions include the areas of: company pilot training, fatigue management, documentation, and aircraft operations.

The ATSB has issued four recommendations concurrent with the release of this report. The first three recommendations address the potential use of alcohol and drugs by safety-sensitive personnel in the Australian aviation industry, and options to manage the safety risk to the travelling public of that potential use. The fourth recommendation addresses the CASA Air Operator Certificate Safety Trend Indicator surveillance methodology. In addition, two Safety Advisory Notices have been issued to CASA relating to pilot manipulation of the Cherokee Six fuel selector and development by operators of pilot induction training programs.

Download Final Report
[Download  PDF: 1.11MB]
General details
Date: 26 September 2002   Investigation status: Completed  
Time: 1708 hours EST    
Location   (show map): Hamilton Island, Aero.    
State: Queensland   Occurrence type: Collision with terrain  
Release date: 18 March 2004   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-32  
Aircraft registration VH-MAR  
Serial number 32-40920  
Type of operation Charter  
Damage to aircraft Destroyed  
Departure point Hamilton Island, QLD  
Departure time 1708 hours EST  
Destination Lindeman Island, QLD  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command Commercial 19.2 1300
  Crew Passenger Ground Total
Fatal: 1 5 0 6
Total: 1 5 0 6
Last update 13 May 2014