CIRCUMSTANCES:

"The aircraft was conducting a night DEPARTURE from Runway 36 at Wondai, Queensland. After an apparently normal take-off, it struck the ground 600 metres beyond the end of the runway in a shallow, wings level descent and at high speed. The aircraft was destroyed by impact forces and fire, and five of the six occupants on board were killed.

3. FINDINGS

3.1 The pilot was medically fit, correctly licenced and qualified to undertake the flight.

3.2 There were no significant meteorological conditions existing at the time of the accident, but the night was dark with no moon and no visible horizon.

3.3 There was evidence of influences which could have resulted in the pilot experiencing the effects of fatigue and/or stress at the time of the accident.

3.4 The pilot received no formal ""human factors"" education during his instrument flying training.

3.5 The aircraft became airborne after a take-off roll of about 900 metres and probably reached a height of about 70 feet (21 metres) above the level of the runway before commencing a shallow descent.

3.6 The pilot transmitted an airborne call very soon after lift-off.

3.7 The aircraft speed at impact was approximately 183 knots.

3.8 The aircraft was in controlled flight, wings level and in a shallow descent at impact.

3.9 The aircraft landing gear and flaps were in the retracted position at impact.

3.10 No evidence was found that the aircraft was not capable of normal operation at the time of the accident.

4. FACTORS

The circumstances leading to the development of this accident could not be established conclusively. However, the evidence supports the following as probable factors

4.1 The pilot might not have been aware of the human factors aspects associated with dark night take-offs.

4.2 The pilot could have been influenced by stress and/or fatigue.

4.3 The aircraft was taking off towards dark textureless terrain and no visible horizon.

4.4 By transmitting his airborne call very soon after lift-off, the pilot was not devoting his full attention to flying the aircraft.

4.5 The pilot became disorientated and placed the aircraft in a shallow descent as it accelerated after take-off.

5. SAFETY ACTION

A search of the Bureau's records revealed a number of accidents with circumstances generally similar to this accident. With some exceptions, a pattern emerged in which total pilot experience was moderate to high but hours on type were comparatively low. Pilot age was typically 40-60 years.

The Bureau is undertaking a detailed analysis of these accidents with the aim, among others, of producing a profile of the ""at risk"" pilot. The results of the study will be published in the BASI Journal. Some other aspects of this accident have also been identified as areas which warrant further research. These include

5.1 Instrument rating tests and their effectiveness, particularly in such areas as the transition from visual to instrument flight and test effectiveness when conducted in aircraft of significantly lower performance than that normally flown by the pilot.

5.2 The training methods used in night take-off/no visible horizon situations their effectiveness."

RECCOMENDATIONS:

6.1 It is expected that at least one safety enhancement recommendation will be made as a result of this investigation.

Circumstances:

Witnesses reported seeing the aircraft take off toward the south-west and climb to a height of between 100 and 150 feet above the ground. It then turned right and flew past the witnesses with the wheels about one metre above ground level. As the aircraft crossed the strip, it entered a 15 degree climb to a height of about 150 feet before rolling inverted and diving through trees into the ground. On-site examination showed that the aircraft passed through the treetops at an angle of 80 degrees nose down. The right wing then struck another tree and was torn off. The aircraft attitude at ground impact was about 40 degrees nose down. No evidence was found of any pre-existing defects in the aircraft. Each aircraft seat was fitted with two seat belt systems - an aerobatic harness and a lap/sash type harness. The pilot was wearing the aerobatic harness at impact, but his lap/sash harness was not secured. The rear seat aerobatic harness was firmly fastened on the seat cushion, but the lap sash belt was not secured. This harness consisted of a short lap belt and a one-piece lap/shoulder strap. Tests showed that, if the lap/shoulder strap had been looped over the rear control column, it could have caused a control restriction at about 3/4 right and 3/4 forward control column travel. However, there was no evidence that the strap had fouled the control column in this instance. On a number of occasions during the past few years, the pilot had complained of heart disturbances. He underwent tests but the results were normal. In the week prior to the accident the pilot had reported feeling faint and almost blacking out during flight. He was reported to have planned to consult a medical practitioner on this matter on the Tuesday following the accident. The postmortem examination on the pilot found evidence of a chronic inflammatory disorder of the heart muscle known as myocarditis. This condition can cause disturbances of heart rhythm. However, specialist assessment of the available medical and postmortem information concluded that physical incapacitation of the pilot was a most unlikely factor in the accident. The cause of the accident was not positively determined.

Significant Factors:

The following factor was considered relevant to the development of the accident:

The pilot was conducting an aerobatic manoeuvre at an unnecessarily low height.

Circumstances:

The aircraft was observed to land about halfway along a 490 metre long north-south grass strip. It became airborne again and appeared to climb slowly before veering left and disappearing from view behind trees. The aircraft failed to reappear and was located a short time later having crashed inverted adjacent to a road. The investigation revealed that, after liftoff from the strip, the aircraft had struck and severed power lines 82 metres beyond the end of the strip and eight metres above ground level. It continued to fly for a further 450-500 metres before striking the upper branches of 17-metre-high trees in a nose down attitude at a bank angle of approximately 90 degrees. Ground impact was 24 metres beyond the trees. The purpose of the flight was practice for a forthcoming commercial pilot's licence flight test for the pilot-under-instruction. His task was to locate and then conduct an airborne inspection of the strip and decide whether or not it was suitable for landing. The strip was regularly used for this purpose by the training organisation. It was assessed as a difficult strip because of its approaches and comparative short length. Pilots under training were, therefore, expected to decide against landing. A decision to attempt a landing would be countered by the instructor. The instructor (pilot-in-command) was familiar with the strip and was aware of the training organisation's policy that students were not to attempt to land on the strip. No fault was found with the aircraft, including the engine and flight controls, which might have contributed to the accident. The aircraft configuration at impact was landing gear up and flaps set at 20 degrees. (This is the flap setting listed in the Pilot's Operating Handbook for a balked landing.) The carburettor heat control was in the off position. Information from the Bureau of Meteorology indicated that the local wet and dry bulb temperatures at the time of the accident were 15 and 19 degrees Celsius, respectively. These figures indicate the probability of carburettor icing was moderate at cruise power and high at descent power. If icing was present, and the intention was to fly an approach to the strip and then conduct an overshoot, the performance of the engine could have been affected to the extent that a landing was unavoidable. Carburettor icing could also have affected the aircraft's climb performance after becoming airborne again from the strip. The evidence indicates that the wires had been cleanly severed by the propeller and had not contacted any other part of the aircraft. The effect of the collision with the wires on the aircraft's performance is difficult to quantify, but it is noteworthy that the aircraft flew for a further 450-500 metres after hitting the wires. It was not determined how far from the end of the strip the aircraft became airborne again. The angle from ground level at the end of the strip to the power line was 5 degrees. The Pilot's Operating Handbook indicates that in a maximum rate of climb configuration (full power, flaps up), the aircraft's climb angle is about 5 degrees. If the aircraft became airborne near the end of the strip, it might not have had the capability to climb above the level of the wires, particularly if the flap setting at this time was 20 degrees. Two kilometres beyond the end of the strip is a ridge line which rises 200 metres above the elevation of the strip. The accident site was in a valley which ran to the east of this ridge line, the position of the wreckage being some 200 metres left of the strip centreline but at substantially the same elevation as the strip. It is possible that the aircraft was deliberately flown along the valley to avoid the high ground and in an attempt to increase performance. The attitude of the aircraft when it struck the trees was indicative of the pilot having lost control.

Factors

The following factors were considered relevant to the development of the accident:

1. Atmospheric conditions were conducive to the formation of carburettor ice.

2. For reasons which could not be established, the aircraft struck and severed power lines.

3. The pilot lost control of the aircraft.

At approximately 1740 hours on 11 May 1990 Cessna 500 Astec Eagle aircraft registered VH-ANQ crashed into the eastern slopes of Mt Emerald, Queensland.

VH-ANQ was engaged in operating a charter flight with one crew member and ten passengers. All occupants received fatal injuries as a result of the impact, and the aircraft was destroyed.

History of the flight

Cessna 500 VH-ANQ was operating the Proserpine to Mareeba leg of a charter flight. The aircraft departed Proserpine at 1635 hours on 11 May 1990. It was being operated by Air North Queensland Pty Ltd, a Cairns based charter company.

The charter flight had been organised to transport members of five local government authorities from the Cairns/Atherton Tablelands area to a Local Government Association Conference at Airlie Beach, Queensland. The aircraft departed Cairns on the morning of 10 May 1990 and proceeded to Mareeba, to emplane further passengers, before continuing to the destination, Proserpine. The pilot and passengers remained at the conference facility overnight.

The pilot had submitted a flight plan, prior to departure from Cairns, for both the outbound flight to Proserpine and the return flight to Cairns. Late the following morning he submitted a further flight plan, by telephone, for the return flight to Cairns. The flight plan details, with the exception of the fuel endurance which had been increased to 177 minutes ex Proserpine, were the same as the previously submitted plan. The plan indicated that the flight would follow Instrument Flight Rules (IFR) and depart Proserpine at 1630 hours with a planned cruising altitude of Flight Level 330 (approximately 33,000 feet). The aircraft was planned to track via overhead Townsville then direct to Mareeba with a flight time interval of 68 minutes.

Departure from Proserpine was reported as 1635 hours and the aircraft was cleared to climb to Flight Level 330. The estimated arrival time at Mareeba was 1743 hours. The flight apparently continued normally and at 1726 hours the aircraft was cleared to descend to Flight Level 170 and instructed to call Cairns Approach. (Cairns Approach controls the airspace down to 6,000 feet above mean sea level above Mareeba Airport which has an elevation of 1,560 feet).

On first contact with Cairns Approach, the pilot advised that the aircraft was tracking for Mareeba via the 163 radial at 41 miles (76 kilometres) DME (Distance Measuring Equipment) from Biboohra. (There are no radio navigational aids at Mareeba, the nearest aids for tracking and instrument approach purposes are at Biboohra, about 16 kilometres north of Mareeba). The aircraft was advised to maintain Flight Level 170 but a short time later was cleared to descend to Flight Level 120. The pilot stated that he would not be dosing down the engines at Mareeba and that his estimated departure time was 1750 hours.

At 1735 hours VH-ANQ was cleared to descend to 10,000 feet and one minute later the pilot advised that the aircraft was "approaching over Mareeba and visual". Cairns Approach advised VH-ANQ that there would be a short delay at 10,000 feet and following a request from the pilot gave approval for the aircraft to circle over Mareeba.

At 1740:22 hours, one minute and 14 seconds after the last transmission from VH-ANQ, Cairns Approach instructed the aircraft to descend to 7,000 feet. This transmission, and other subsequent transmissions to the aircraft, went unanswered.

The Civil Aviation Authority commenced Search and Rescue procedures. An aircraft operating in the area reported hearing the signal from an Emergency Locator Transmitter at about 1820 hours. However, the aircraft was unable to determine the exact location of the transmitter because of the adverse weather in the area.

The wreckage of VH-ANQ was ultimately located on the eastern slopes of Mt Emerald, 15 kilometres south of Mareeba Airport, by searching helicopters at 0240 hours on 12 May 1990.

This accident was unusual in that the last report by the pilot indicated that the aircraft was at 10,000 feet and on a track that was 55 kilometres to the east of the accident site. There was no substantiated, and very little circumstantial evidence to suggest what caused the aircraft to descend 6,400 feet and to be displaced a considerable distance to the west of track. As a result, the causal factors associated with this accident remain undetermined.

Circumstances:

The pilot of VH-CXE was flying in company with, but about two miles ahead, of another aircraft flown by his daughter. VH-CXE was observed apparently flying a straight in approach to the sealed Runway 01 at Mt Margaret and to then go around from the approach (there was a 15 knot crosswind from the right at the time). The following aircraft also went around from its initial approach and flew another circuit. Neither occupant of this aircraft saw VH-CXE during the second circuit and a radio query failed to bring any response. A fire was noticed on the western threshold of the dirt cross strip, but this was not associated with VH-CXE. Later, when VH-CXE could not be located, the position of the fire was examined and confirmed as the wreckage of VH-CXE. Investigation revealed that the aircraft had struck the ground in a near vertical nose-down attitude while rotating left. The wreckage had burnt out and the extent of fire damage precluded a complete examination of the aircraft and its systems. However, no evidence was found to suggest that the aircraft was not capable of normal operation prior to the accident. It was established that the landing gear was locked down, the wing flaps were fully extended, and the engine was producing substantial power at impact. It was not possible to determine if the pilot experienced incapacitation prior to the accident.

Significant Factors:

The following factors were considered relevant to the development of the accident:

1. The aircraft struck the ground, probably in uncontrolled flight, for reason(s) which could not be determined.

Circumstances:

The pilot, accompanied by two employees, was carrying out an aerial inspection of a harvesting operation in a large open paddock. The aircraft had approached from the north, flying at approximately 150 feet above ground level, and carried out a right hand orbit. It then proceeded for a short distance in a southerly direction, before entering a steep descending turn to the left towards a three wire powerline positioned north-south across the paddock, the spans of which were approximately 30 feet above ground level. Approaching the powerline the aircraft was observed to climb rapidly, and a noise like a breaking stick was heard as the left hand wingtip contacted the centre wire of the powerline. The aircraft continued to climb steeply to about 80 feet above ground level. It faltered momentarily before stalling and impacting the ground 100 metres east of the powerline. The aircraft impacted on its left hand wing and nose. It bounced a further 25 metres while turning inverted and became engulfed in a ball of fire which reduced it to ashes. In 1988 the pilot received a serious head injury which resulted in the Civil Aviation Authority not renewing his pilot licence pending additional information from the pilot regarding his medical condition. The pilot did not provide sufficient information but continued to fly up to the time of the accident.

Significant Factors:

The following factors were considered relevant to the development of the accident:

1. The pilot was conducting a low flying operation.

2. The pilot probably saw the powerline too late to avoid it.

3. The aircraft stalled at a height from which it was too low to effect a recovery.

Circumstances:

While the helicopter was flying at about 60 knots and 400 feet above the ground, the pilot heard a loud bang. The helicopter yawed slightly, and the pilot felt an airframe vibration. As the pilot reduced airspeed and initiated a descent, he saw the red fire warning light illuminated and realised that the engine had failed. After a successful autorotative landing, the pilot extinguished several small scrub fires under the helicopter tail boom. These fires were ignited by hot metal ejected from the engine. He also extinguished a small oil fire in the engine bay. The engine failure resulted from the failure of the intermediate gear/pinion in the reduction gearbox. The gear failed due to fatigue cracking which commenced at an overstress crack. This crack, plus similar cracks found in the root of five adjacent gear teeth, probably occurred as a result of main rotor blade strikes which occurred when the helicopter rolled over during a ground run approximately 765 hours time-in-service earlier. After this earlier rollover accident, the reduction gearbox was inspected and returned to service in accordance with the Turbomeca Arriel 1 Engine Maintenance Manual. The engine manufacturer is aware of two other total ruptures of intermediate gears of the same modification status as was fitted in the reduction gearbox of VH-HRR. Eight more failures of intermediate gears of a later modification status have been detected by pilots, without ensuing engine failures, because of warning lights triggered by metal particles on an electric magnetic plug.

Significant Factors:

The following factors were considered relevant to the development of the accident

1. VH-HRR experienced a rollover accident involving main rotor blade strikes approximately 765 hours time-in service previously.

2. Engine maintenance manual inspection requirements do not necessarily require overhaul or crack testing of a reduction gearbox after main rotor strikes/sudden stoppages.

3. Fatigue cracking commenced at an overstress crack on the intermediate gear within the reduction gearbox.

Recommendations:

It is recommended that the CAA liaise with the engine manufacturer to consider the desirability of incorporating more stringent inspection requirements in the engine maintenance manual to detect cracks in components after rotor blade strikes/sudden stoppages. RESPONSE TO S The CAA has been in contact with the engine manufacturer (Turbomeca) and the relevant certification authority (DGAC) with respect to reduction gearbox failures. Turbomeca intends to be more precise in the wording of the Engine Maintenance Manual concerning inspections to be carried out after rotor blade strikes/sudden stoppages.

The Boeing B747 was under radar control by Sydney Approach (North). The aircraft had descended to 2000 feet and intercepted the Runway 16 localizer in preparation for an ILS approach to Sydney (Kingsford Smith) International Airport. The Piper PA28 was engaged in a solo navigation exercise from Bankstown Airport which is 16 km west of Sydney International. The exercise required the Piper to depart Bankstown tracking in a northerly direction along the Lane of Entry (LOE) outside controlled airspace (OCTA) while remaining below 2000 feet. The LOE abutts the western boundary of the Sydney Control Zone (CTR) and the Sydney Control Area (CTA).

The surface wind in the Sydney and Bankstown areas was light and variable the cloud base 3500 to 4000 feet and the visibility 10 km or more. The PA28 departed Runway 29 at Bankstown and the pilot identified and flew over the first aeronautical ground strobe light (at Clyde) marking the departure track in the LOE but was unable to sight the second light (at Carlingford). The pilot did not make good the required track of 007 degrees magnetic to follow the LOE but allowed the aircraft to fly on into the Sydney CTR on a north-easterly heading. The pilot subsequently recognised Macquarie University and then changed course to depart the Sydney CTR.

As the B747 was intercepting the glideslope at 2000 feet the Second Officer saw a light aircraft ahead at the same level. It was in the 12 30 relative position tracking generally towards the B747 and crossing from right to left. The Captain and First Officer of the B747 also sighted the light aircraft as it passed abeam to the left at an estimated 200 feet horizontally and at the same altitude. The B747 crew identified the aircraft as a PA28 but did not observe the rotating beacon on the PA28. The PA28 pilot first sighted the B747 as it passed abeam to the left. The Sydney Approach (North) controller first noticed a faint primary paint radar contact very close to the B747 at about the same time as the B747 crew reported the near miss. The radar return became stronger and recognisable as the aircraft turned to the North. At the time of the incident the PA28 pilot had a total of 110 hours flying experience. The pilot had flown northbound in the LOE on three previous occasions; twice dual and once solo. The last time being some 10 weeks before the incident. Prior to boarding the aircraft the pilot's flight plan was checked by an instructor but formal briefing on the particular navigation exercise or the LOE was not provided.

The procedure in place at the relevant flying organisation relied on the student to find an available instructor to provide flight plan checking and exercise briefings. No self-briefing aid eg video was available at the Bankstown Pilot Briefing Office for pilots to familiarise themselves with the features of the LOE. The PA28 pilot stated that after take-off on Runway 29 Centre at Bankstown the aircraft was climbed straight ahead to 1000 feet before commencing a right turn. The pilot then identified the Rosehill refinery and the first ground strobe light. The aircraft was then on a heading of about 013 degrees magnetic from Bankstown. After passing over the first ground strobe light the pilot was unable to find the next strobe light at Carlingford. Attempts to find the second light were made without reference to the aircraft heading and the pilot then became directionally disoriented. The position of the Carlingford light was correctly depicted on the current Visual Terminal Chart being used by the pilot. Eyewitness evidence indicates that the Carlingford strobe light was operating.

The PA28 was flown on headings well to the right of that required to maintain correct track from the first ground strobe light to the second one. This led to a penetration of the Sydney CTR and conflict with the inbound B747. Sydney Approach (North) was not able to detect the impending conflict as the PA28 was not transponding. It was not required to have an active transponder and there were no primary radar returns which was probably due to tangential fading. The PA28 was not displayed until the B747 and the PA28 were in close proximity and the PA28 changed heading. Sydney Approach Control (North) is not able to identify monitor or readily communicate directly with aircraft which stray into the Sydney CTR from the LOE. The rotating beacon of the PA28 was ineffective in giving the B747 crew early warning of conflicting traffic. The PA28 was sighted against a background of suburban housing presenting a nearly head-on aspect. None of the B747 crew recalled observing the PA28's rotating beacon. The B747 crew considered that the PA28 was sighted in sufficient time for avoiding action to have been taken had it have been warranted. Neither aircraft took avoiding action. The performance of the Sydney air traffic control radar was not a factor.

RECOMMENDATIONS:

For CAA Central and NSW Offices.

Consideration should be given to the following

a. Establishment of facilities whereby ATC can identify monitor and communicate directly with all aircraft which enter the Sydney CTR and CTA from the Bankstown LOE without authorisation.

b. Revising the inbound and outbound tracks in the LOE so as to minimise the risk of traffic penetrating the Sydney CTR and CTA.

c. Installing a more effective visual guidance system in the Bankstown LOE then the present aeronautical ground strobe light facilities.

d. Amending the Sydney VTC so as to accurately show the relative positions of aeronautical ground lights and other significant land marks.

e. Ensuring that all unserviceable aeronautical ground lights are repaired within hours of the notification of failure.

f. Establishing a procedure which enables Sydney ATC to identify aircraft intentionally operating in R409 A&B.

g. Providing self-briefing facilities at the Bankstown pilot briefing office as a matter of urgency for pilots to study prior to operations through the LOE.

h. Considers a requirement for all Australian registered general aviation aircraft to be fitted with multiple rapid flashing omnidirectional white strobe lights.

i. Taking action to ensure that pilots undergoing navigation training are properly supervised and maintain a satisfactory level of proficiency in negotiating the Bankstown LOE.

This accident was not the subject of an on site investigation. CIRCUMSTANCES: "The pilot stated that when she was on final approach to land on runway 28, and at about 30 feet above ground level, another aircraft which had previously been stationary near the threshold moved to the middle of the runway and began to take off. The pilot stated that there was no time or avenue for a go-around and avoiding action was taken. During the avoiding manoeuvre the aircraft stalled and impacted the ground near the edge of the runway."

CIRCUMSTANCES: "During a routine maintenance inspection on 2 March 1988 numerous creases were found in the surfaces of both wings. In addition, spar cap rivets were found to be damaged by shear load. The damage was indicative of the aircraft having been subjected to excessive positive `G' loading in flight. The circumstances leading to permanent deformation of the wings were not determined."