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What happened

At about 1107 on 1 October 2012, the pilot-owner of a vintage de Havilland DH-84 Dragon Mk 2, registered VH-UXG, took off on a private flight from Monto to Caboolture, Queensland. On board with the pilot were five passengers, baggage and equipment. The pilot was not qualified and the aircraft not equipped for instrument flight. The weather on the coast and extending inland included low clouds and rain.

At 1315, the pilot radioed air traffic control (ATC) and requested navigation assistance, advising that the aircraft was in cloud. Over the next 50 minutes ATC provided assistance to the pilot and a search and rescue (SAR) helicopter was dispatched to the area. From the pilot’s radio calls it was apparent that he was unable to navigate clear of the cloud. Radio contact was intermittent and no transmissions from the aircraft were received after 1405.

An extensive search was initiated, and the aircraft wreckage was located on 3 October in high terrain. The aircraft was destroyed and there were no survivors.

What the ATSB found

With no or limited visual references available in and near cloud, it would have been very difficult for the pilot to maintain control of the aircraft. After maintaining control in such conditions for about an hour, and being unable to navigate away from the mountain range, the pilot most likely became spatially disoriented and lost control of the aircraft before it impacted the ground.
Due to the limited radio and radar coverage in the area, the ability of ATC and the SAR helicopter to assist was limited. However, the ATSB found that there were areas of potential improvement in the management of in-flight emergencies and coordination between ATC and SAR aircraft.

What's been done as a result

Airservices Australia and the Australian Maritime Safety Authority agreed to conduct a comprehensive review of their existing memorandum of understanding to ensure the effectiveness of collaborative in-flight emergency responses. The review is anticipated to be completed by the first quarter of 2014.

Safety message

Though it remains unclear precisely how the aircraft came to be in instrument conditions, this accident highlights the importance of pre- and in-flight planning and decision-making in limiting exposure to risk. It is important for pilots to incorporate approved weather forecasts, knowledge of the terrain, and diversion options into their flight planning, to plan for contingencies prior to and throughout a flight, and to carry out those plans well before encountering difficulty.

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Updated: 9 October 2013

The ATSB is finalising its draft report, which will be sent to directly involved parties (DIP) in October 2013. Feedback from those parties on the factual accuracy of the draft report over the 28‑day DIP period will be considered for inclusion in the final report, which is anticipated to be released to the public in December 2013.

 

 

Updated: 17 April 2013

The investigation is continuing into the collision with terrain involving de Havilland DH‑84 Dragon, registered VH-UXG, which occurred 36 km south-west of Gympie, Queensland on 1 October 2012.

The ATSB has reviewed numerous witness reports and radio recordings, and it appears that the aircraft flew a roughly direct course from Monto before encountering what the pilot described to air traffic control (ATC) as ‘full cloud’ about 2 hours into the flight. The evidence at this stage indicates that the aircraft flew around the Borumba Dam, Imbil, and Kandanga areas for about an hour, probably mostly in or around cloud that would typically be described as instrument meteorological conditions. 

Radio and radar coverage in the area was limited. As such, ATC was unable to direct the pilot to an area of known visual conditions because of the extent of the cloud cover and uncertainty over the aircraft’s position. 

To date, there are no indications of an aircraft malfunction. However, the ATSB has retained the aircraft wreckage in case of a need for further examination. Several items and components that were retrieved from the accident site have been examined, including some aircraft instruments. Data was successfully downloaded from an aircraft GPS receiver that was found among the aircraft wreckage, but it did not contain information pertinent to the accident flight. 

Following a burn-off of the area and a period of heavy rain, three ATSB investigators returned to the accident site to search for another GPS receiver that was known to be installed in the aircraft. This GPS was not found but investigators located the instrument face of the aircraft’s vertical speed indicator (Figure 1), which may provide further evidence.

Figure 1: Face of vertical speed indicator

Speed indicator face of the de Havilland DH 84 Dragon 

The investigation is continuing and will include examination of the:

  • air traffic radar and radio recordings
  • aircraft wreckage and instruments
  • aircraft’s maintenance records
  • emergency response
  • weather information
  • witness reports.

A final report is scheduled for release in October 2013. 


The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.

 
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Preliminary report release: 8 November 2012

The ATSB has released its preliminary factual report into the collision with terrain that occurred 36 km south-west of Gympie, Queensland on 1 October 2012. The information contained in the report is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that may alter the circumstances as depicted in the preliminary report. As such, no analysis or findings are included in the report.

At about 1107 Eastern Standard Time on 1 October 2012, a de Havilland Aircraft Pty Ltd DH-84 Dragon, registered VH-UXG, took off from Monto on a private flight to Caboolture, Queensland under the visual flight rules. At 1315, the pilot contacted Brisbane Radar air traffic control (ATC) and advised that the aircraft’s position was about 37 NM (69 km) north of Caboolture and requested navigation assistance. At 1318, the pilot advised ATC that the aircraft was in ‘full cloud’.

For most of the remainder of the flight, the pilot and ATC exchanged communications, at times relayed through a commercial flight and a rescue flight in the area due to the limited ATC radio coverage in the area at low altitude. At 1348, the pilot advised Air Traffic Control that the aircraft had about an hour’s endurance remaining. The pilot’s last recorded transmission was at 1404.

A search for the aircraft was coordinated by Australian Search and Rescue (AusSAR). The aircraft wreckage was located on 3 October 2012, about 87 km north-west of Caboolture.

The aircraft was destroyed by impact forces. There was no fire. The accident was not survivable and the six occupants were fatally injured.

The ATSB's investigation is continuing and will include examination of the:

  • relevant air traffic radar and radio recordings
  • weather information pertinent to the flight
  • witness reports
  • aircraft’s maintenance records
  • pilot’s records and history, and
  • search and rescue records.

It is anticipated that the investigation will be completed by October 2013.

Read the preliminary factual report.

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 _________

History

 

Updated: 9 October 2013

The ATSB is finalising its draft report, which will be sent to directly involved parties (DIP) in October 2013. Feedback from those parties on the factual accuracy of the draft report over the 28‑day DIP period will be considered for inclusion in the final report, which is anticipated to be released to the public in December 2013.

 

 

Updated: 17 April 2013

The investigation is continuing into the collision with terrain involving de Havilland DH‑84 Dragon, registered VH-UXG, which occurred 36 km south-west of Gympie, Queensland on 1 October 2012.

The ATSB has reviewed numerous witness reports and radio recordings, and it appears that the aircraft flew a roughly direct course from Monto before encountering what the pilot described to air traffic control (ATC) as ‘full cloud’ about 2 hours into the flight. The evidence at this stage indicates that the aircraft flew around the Borumba Dam, Imbil, and Kandanga areas for about an hour, probably mostly in or around cloud that would typically be described as instrument meteorological conditions. 

Radio and radar coverage in the area was limited. As such, ATC was unable to direct the pilot to an area of known visual conditions because of the extent of the cloud cover and uncertainty over the aircraft’s position. 

To date, there are no indications of an aircraft malfunction. However, the ATSB has retained the aircraft wreckage in case of a need for further examination. Several items and components that were retrieved from the accident site have been examined, including some aircraft instruments. Data was successfully downloaded from an aircraft GPS receiver that was found among the aircraft wreckage, but it did not contain information pertinent to the accident flight. 

Following a burn-off of the area and a period of heavy rain, three ATSB investigators returned to the accident site to search for another GPS receiver that was known to be installed in the aircraft. This GPS was not found but investigators located the instrument face of the aircraft’s vertical speed indicator (Figure 1), which may provide further evidence.

Figure 1: Face of vertical speed indicator

Speed indicator face of the de Havilland DH 84 Dragon 

The investigation is continuing and will include examination of the:

  • air traffic radar and radio recordings
  • aircraft wreckage and instruments
  • aircraft’s maintenance records
  • emergency response
  • weather information
  • witness reports.

A final report is scheduled for release in October 2013. 


The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.

 

Update: 9 October 2012

ATSB investigators have worked alongside Queensland police sifting through the aircraft wreckage and examining the accident site in detail. Although the site was somewhat difficult to access, and the extent of the damage to the aircraft made conditions difficult, the investigators have now finished the on-site phase of the investigation and will shortly commence drafting a preliminary factual report. The ATSB aims to release this report to the public within 30 days of the accident.

Despite the on-site challenges, the ATSB investigators:

  • surveyed the site in detail
  • interviewed a number of witnesses who saw the aircraft prior to the accident
  • retrieved a Global Positioning System unit circuit board from the wreckage, although impact damage to the board may preclude the recovery of any data
  • retained several aircraft items and components for further examination including:
    • both engines and propellers
    • a number of aircraft instruments
    • several electrical and communications devices from which relevant data may be able to be recovered.

As part of the ongoing investigation, investigators will examine the:

  • relevant air traffic radar and radio recordings
  • weather information pertinent to the flight
  • witness reports
  • aircraft’s maintenance records
  • pilot’s records and history.

 

 

Update: 3 October 2012

The ATSB is investigating an accident involving a DH 84 Dragon aircraft that was reported missing in Queensland on 1 October 2012.

The aircraft departed Monto that day with six persons on board. The pilot later reported entering cloud and requested assistance from air traffic control to exit those conditions. Communication with the aircraft was subsequently lost.

A search for the aircraft was coordinated by Australian Search and Rescue (AusSAR). The aircraft wreckage was located south-west of Gympie on 3 October 2012.

The ATSB has dispatched a team of four investigators to begin the on-site phase of the investigation. The team comprises experts in aircraft operations, aircraft maintenance and flight systems.

Investigators will be:

  • examining the wreckage and surrounds for evidence
  • interviewing witnesses and others involved in the aircraft’s operation
  • obtaining the available recorded information, such as radio and radar data
  • examining documentation relating to the aircraft’s maintenance history.

If you have any information about the accident please call the ATSB on 1800 020 616.

The ATSB aims to finalise its investigation within 12 months.

 

Download Preliminary Report
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Safety issue

AO-2012-130-SI-01 -  

Provision of assistance to aircraft in distress

Though airborne search and rescue service providers were regularly tasked to provide assistance to pilots in distress, there was limited specific guidance on the conduct of such assistance.

Issue Number:AO-2012-130-SI-01
Who it affects:Aeroplane and helicopter search and rescue (SAR) service providers
Status:Adequately addressed

 

General details

Date: 01 Oct 2012 Investigation status: Completed 
Time: 1405 EST Investigation type: Occurrence Investigation 
Location   (show map):36 km SW of Gympie Occurrence type:VFR into IMC 
State: QLD Occurrence class: Operational 
Release date: 19 Dec 2013 Occurrence category: Accident 
Report status: Final Highest injury level: Fatal 
 

Aircraft details

Aircraft manufacturer: de Havilland Aircraft Pty Ltd 
Aircraft model: DH-84 
Aircraft registration: VH-UXG 
Serial number: 6077 
Type of operation: Private 
Sector: Piston 
Damage to aircraft: Destroyed 
Departure point:Monto, Qld
Destination:Caboolture, Qld
 
 
 
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Last update 25 March 2014