Douglas DC3C-S1C3G, VH-EDC, Botany Bay, New South Wales, 24 April 1994

Summary

On Sunday 24 April 1994, at about 0910 EST, Douglas DC-3 aircraft VH-EDC took off from runway 16 at Sydney (Kingsford-Smith) Airport. The crew reported an engine malfunction during the initial climb and subsequently ditched the aircraft into Botany Bay. The DC-3 was on a charter flight to convey a group of college students and their band equipment from Sydney to Norfolk Island and return as part of Anzac Day celebrations on the island. All 25 occupants, including the four crew, successfully evacuated the aircraft before it sank.

The investigation found that the circumstances of the accident were consistent with the left engine having suffered a substantial power loss when an inlet valve stuck in the open position. The inability of the handling pilot (co-pilot) to obtain optimum asymmetric performance from the aircraft was the culminating factor in a combination of local and organisational factors that led to this accident. Contributing factors included the overweight condition of the aircraft, an engine overhaul or maintenance error, non-adherence to operating procedures and lack of skill of the handling pilot.

Organisational factors relating to the company included:

• inadequate communications between South Pacific Airmotive Pty Ltd who owned and operated the DC-3 and were based at Camden, NSW and the AOC holder, Groupair, who were based at Moorabbin, Vic.;
• inadequate maintenance management;
• poor operational procedures; and
• inadequate training.

Organisational factors relating to the regulator included:

• inadequate communications between Civil Aviation Authority offices, and between the Civil Aviation Authority and Groupair/South Pacific Airmotive;
• poor operational and airworthiness control procedures;
• inadequate control and monitoring of South Pacific Airmotive;
• inadequate regulation; and
• poor training of staff.

During the investigation, a number of interim safety recommendations were issued by the Bureau. These recommendations, and the CAA's responses to them, are included in this report.