Aviation safety investigations & reports

Cessna Aircraft Company 404, VH-ANV

Investigation number:
Status: Completed
Investigation completed


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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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Technical Analysis

(Cessna 404, VH-ANV Jandakot WA, 11 August 2003)


At 0735 UTC on 11 August 2003, VH-ANV was cleared on a MANTL 1 departure from runway 24R at Jandakot airport. Onboard were the pilot and five passengers. The aircraft called ready and was cleared to climb to 3,000 feet. The aircraft rotated and the tower staff noticed a sound similar to an asymmetric operation. The aircraft was turned left and subsequently impacted the ground to the southeast of the tower near the NDB site. This Technical Analysis Investigation report should be read in conjunction with ATSB report BO/200303579.

General details
Date: 11 August 2003   Investigation status: Completed  
Time: 1537 hours WST    
Location   (show map): Jandakot, Aero.    
State: Western Australia   Occurrence type: Fuel starvation  
Release date: 23 March 2005   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 404  
Aircraft registration VH-ANV  
Serial number 4040820  
Type of operation Aerial Work  
Damage to aircraft Destroyed  
Departure point Jandakot, WA  
Departure time 1535 hours WST  
Destination Jandakot, WA  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command Commercial 16606
  Crew Passenger Ground Total
Fatal: 0 2 0 2
Serious: 1 3 0 4
Total: 1 5 0 6
Last update 13 May 2014