EXECUTIVE SUMMARY
On 11 August 2003, at about 1535 Western Standard Time, a Cessna
Aircraft Company 404 Titan (C404) aircraft, registered VH-ANV, took
off from runway 24 right (24R) at Jandakot Airport, WA. One pilot
and five passengers were on board the aircraft. The flight was
being conducted in the aerial work category, under the instrument
flight rules.
Shortly after the aircraft became airborne, while still over the
runway, the pilot recognised symptoms that he associated with a
failure of the right engine and elected to continue the takeoff.
The pilot retracted the landing gear, selected the wing flaps to
the up position and feathered the propeller of the right
engine.
The pilot later reported that he was concerned about clearing a
residential area and obstructions along the flight path ahead,
including high-voltage powerlines crossing the aircraft's flight
path 2,400 m beyond the runway. The aircraft was approximately 450
m beyond the upwind threshold of runway 24R when the pilot
initiated a series of left turns. Analysis of radar records
indicated that during the turns, the airspeed of the aircraft
reduced significantly below the airspeed required for optimum
single-engine performance.
The pilot transmitted to the aerodrome controller that he was
returning for a landing and indicated an intention to land on
runway 30. However, the airspeed decayed during the subsequent
manoeuvring such that he was unable to safely complete the approach
to that runway. The pilot was unable to maintain altitude and the
aircraft descended into an area of scrub-type terrain, moderately
populated with trees. During the impact sequence at about 1537, the
outboard portion of the left wing collided with a tree trunk and
was sheared off. A significant quantity of fuel was spilled from
the wing's fuel tank and ignited. An intense post-impact fire broke
out in the vicinity of the wreckage and destroyed the aircraft.
Four passengers and the pilot vacated the aircraft, but
sustained serious burns in the process. One of those passengers
died from those injuries 85 days after the accident. A fifth
passenger did not survive the post-impact fire.
The investigation assessed that the aircraft was below its
maximum permitted take-off weight and within centre of gravity
limits at the time of the accident. Analysis of radar data
indicated that the aircraft was operating significantly below the
optimum speed for maximum single-engine climb performance for most
of the flight.
A number of factors affect an aircraft's one-engine inoperative
performance, including any variation from the airspeed to achieve
the one-engine inoperative best rate of climb, control inputs made
by the pilot to manage the situation and the effect of
manoeuvring/turning the aircraft. One-engine inoperative climb
performance would have significantly reduced during the turns, with
a loss of at least 25 per cent during a 10 degree angle of bank
turn, 50 per cent during a 20 degree angle of bank turn and more
than 90 per cent had there been a 30 degree angle of bank turn.
Examination of the right engine revealed a material anomaly with
the sleeve bearing from the engine-driven fuel pump. That bearing
exhibited evidence of localised adhesive wear (galling) that had
restricted the rotation of the pump spindle shaft. The bearing had
previously been replaced during the last engine overhaul. Analysis
of the bearing revealed that it had been manufactured from material
that possessed inferior galling resistance when compared with
bearings from similar pumps. The investigation concluded that the
specified material for the replacement sleeve bearing was
inadequate with respect to its galling resistance. High torsional
loads between the spindle shaft and the sleeve bearing had caused
the pump's drive shaft to shear at a critical phase of flight.
Associated with a loss of drive to the pump shaft was a reduction
in fuel pressure, which was insufficient to sustain operation of
the engine at take-off power.
Following the occurrence, the operator modified other C404
aircraft in its fleet to incorporate a warning light to indicate
low fuel pressure. The ATSB has previously issued three
recommendations (see ATSB report BO/200105618) relevant to pilot
training for engine-out operations in multi-engine aircraft. Those
recommendations are also relevant to the circumstances of this
occurrence.
Records from the Fire and Emergency Services Authority of
Western Australia (FESA) indicated that the first responding
appliances reached the Jandakot Airport emergency gate, about 1,500
m from the accident site, at 1551:52, about 12.5 minutes after
being notified by the police. The fire fighting vehicles were not
able to track direct to the accident site and had to negotiate
runways and bush tracks. The FESA records indicated that the first
information from the accident site was received at 1558:28, which
stated 'MT is tackling the fire, some persons are out, some persons
are missing.'
Following an occurrence at Bankstown Airport in November 2003,
the ATSB conducted an investigation at the direction of the
Minister for Transport and Regional Services to '…investigate the
effectiveness of the fire fighting arrangements for Bankstown
Airport as they affected transport safety…'. Bankstown Airport is a
General Aviation Aerodrome Procedure (GAAP) aerodrome that had
similar provisions for aerodrome rescue and fire fighting services
(ARFFS) to Jandakot Airport at the time of the occurrence involving
ANV. The ATSB report (200305496) on that investigation is available
on the ATSB website.
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