On 7 May 2005, a Fairchild Aircraft Inc. SA227-DC Metro 23 aircraft, registered
VH-TFU, with
two pilots and 13 passengers, was being operated by Transair on an instrument
flight rules
regular public transport service from Bamaga to Cairns, with an intermediate
stop at Lockhart
River, Queensland. At 1143:39 Eastern Standard Time, the aircraft impacted
terrain in the Iron
Range National Park on the north-western slope of South Pap, a heavily timbered
ridge,
approximately 11 km north-west of the Lockhart River aerodrome. At the time
of the accident, the
crew was conducting an area navigation global navigation satellite system (RNAV
(GNSS)) nonprecision
approach to runway 12. The aircraft was destroyed by the impact forces and
an intense,
fuel-fed, post-impact fire. There were no survivors.
The accident was almost certainly the result of controlled flight into terrain,
that is, an airworthy
aircraft under the control of the flight crew was flown unintentionally into
terrain, probably with
no prior awareness by the crew of the aircraft’s proximity to terrain.
The investigation report
identifies a range of contributing and other safety factors relating to the
crew of the aircraft,
Transair's processes, regulatory oversight of Transair by the Civil Aviation
Safety Authority, and
RNAV (GNSS) approach design and chart presentation. It also details safety
action taken by
various agencies to address the identified safety issues, and includes safety
recommendations
relating to those safety issues that had not been addressed by relevant agencies
at the time of
publication of this report.
Download report body [PDF
7.4mb]
Download report appendices [PDF
12.97mb]
Download Appendix A animation [4.41mb
.isv]
An animation was prepared using
Insight Animation™ software
and is part of this report. A file containing the animation in Insight View™ format
(.isv) is available for download from the ATSB website. This file requires
the installation of an Insight Viewer that can be downloaded from www.flightscape.com/products/view.php at
no charge.
Due to the large file size of this report CD-Roms and hard-copies are available
from the ATSB, to order email ATSBInfo@atsb.gov.au or
telephone 02 6274 6130 or 1800 020 616.
Recommendations
R20070002 | R20070003 | R20070004 | R20070005 | R20070006 | R20070007 | R20070008 | R20070009 | R20070010 | R20070011 | R20060019 | R20060020 |
R20060021 | R20060022 | R20060002 | R20060003 | R20060005 | R20060006
