Interim report released 25 May 2007

On 31 October 2006 at 1955 Eastern Standard Time, PA31-350 aircraft, registered VH-ZGZ, was on descent to Gladstone Airport, Qld when its radar track disappeared from the air situation display in the Brisbane Air Traffic Control Centre. Subsequently, the aircraft was found to have impacted terrain approximately 9 km south-east of Raglan, Qld. The pilot and two passengers were fatally injured. The aircraft was destroyed by impact forces and post-impact fire.

On 31 October 2006, a Piper Aircraft Corporation PA-31-350 Chieftain aircraft, registered VH-ZGZ, was being operated on a private category instrument flight rules (IFR) flight from Emerald to Gladstone, Qld. On board the aircraft were the pilot in command and two passengers. After departing Emerald at 1807 Eastern Standard Time, the flight proceeded apparently normally until the aircraft disappeared from radar while passing about 4,500 ft on descent into Gladstone. It was subsequently determined that the aircraft had crashed 9 km SE of Raglan, approximately 39 km west of Gladstone. The aircraft occupants received fatal injuries.

Conditions in the area of the accident were dark with some rain. Thunderstorms had been forecast but there was no thunderstorm or lightning activity in the area where radar contact was lost.

Recorded radar and voice transmission information indicated that the aircraft was performing normally before it suddenly diverged left from a steady descending flight path and entered a spiral dive.

On-site examination confirmed that the aircraft impacted the ground at high speed in a steep, left spiral descent. The aircraft structure was complete at impact. It was established that at impact, both engines were operating at between 2,200 and 2,400 RPM and both propellers were in the normal operating pitch range. There was evidence that the gyroscopic instruments were functioning. The destruction to the wreckage precluded examination of the electrical and fuel systems, the flight controls, and the autopilot.

A series of maintenance issues involving the aircraft's engines occurred in the period before the accident. However, there was evidence that these had been resolved before the accident flight.

The pilot's experience on the aircraft type was limited, as was his night and instrument flight experience. The dark and very likely cloudy conditions that existed in the area where the aircraft suddenly diverged from its flight path meant that recovery to normal flight could only have been achieved by sole reference to the aircraft's flight instruments. The difficulty associated with such a task when the aircraft was in a steep descent was likely to have been significant.

Interim factual report released 7 November 2007

At about 1215 Eastern Standard Time on 5 October 2006, the pilot of a British Aircraft Corporation 167 Strikemaster aircraft took off from Bathurst, NSW, for a 25-minute joy flight with one passenger. The flight was intended to include high-level aerobatics followed by a low-level simulated strike mission. When the aircraft failed to return, a search was initiated, and the aircraft wreckage was located in the Turon State Forest about 20 km to the NE of Bathurst. The ground impact started a fuel-fed fire that resulted in a large bushfire, which took several days to contain. The pilot and passenger were fatally injured.

On-site and laboratory examination of the wreckage revealed that:

• the engine was producing significant power at the time of impact
• the wing flaps and landing gear were retracted
• the right wing had separated from the aircraft in flight
• the tail components had separated from the aircraft in flight.

As a result of this occurrence, the ATSB briefed the Civil Aviation Safety Authority (CASA) on preliminary findings relating to the wing failure. Subsequent briefings were provided to CASA and the UK Civil Aviation Authority on the failure of the aircraft tail components. CASA has released a number of Airworthiness Bulletins to alert Australian operators of issues relating to Strikemaster and Jet Provost aircraft.

Updated: 21 June 2012

Operators of BAC 167 Strikemaster aircraft are being urged to check the safety of their aircraft following a Coronial inquest into a fatal Strikemaster accident.

On 5 October 2006, a BAC 167 Strikemaster aircraft broke up in flight and crashed into the Turon State Forest (near Bathurst, NSW) during an adventure flight. The pilot and passenger died in the accident.

In 2011, the Office of the NSW State Coroner began a Coronial Inquest into the accident. During evidence at the Inquest, details of the calculation of Fatigue Index (FI) penalties applicable to Strikemaster aircraft was provided.

As a result of this evidence, CASA issued an Airworthiness Bulletin (AWB 02-041 Issue 2). The Bulletin recommends that registered operators and maintenance organisations review the FI records for BAC Strikemaster 167 aircraft and determine if a FI penalty should be applied.

On 7 September 2011, CASA updated the Airworthiness Bulletin to AWB 02-041 Issue 3.

The Airworthiness Bulletin is available on CASA's website at www.casa.gov.au

At about 1215 Eastern Standard Time on 5 October 2006, the pilot of a British Aircraft Corporation 167 Strikemaster aircraft, registered VH-AKY, took off from Bathurst, NSW, for a 25-minute adventure flight with one passenger. The flight was intended to include high-level aerobatics followed by a low-level simulated strike mission. When the aircraft failed to return, a search was initiated, and the aircraft wreckage was located in the Turon State Forest about 20 km to the north-east of Bathurst. The ground impact started a fuel-fed fire that resulted in a large bushfire, which took several days to contain. The pilot and passenger were fatally injured.

The engine was producing significant power at the time of impact and the wing flaps and landing gear were retracted. The right wing and tail had separated from the aircraft. Separation of the right wing was precipitated by pre-existing fatigue cracking in the right wing upper main spar attachment lug.

During the low-level simulated strike mission, the aircraft broke up in flight. The majority of the available evidence was consistent with a break-up initiated by separation of the tail surfaces leading to the separation of the weakened right wing.

As a result of this occurrence, the Australian Transport Safety Bureau (ATSB) briefed the Civil Aviation Safety Authority (CASA) and the UK Civil Aviation Authority on findings relating to the separation of the wing and tail. CASA has released a number of Airworthiness Bulletins to alert Australian operators of issues relating to Strikemaster and Jet Provost aircraft. CASA has also approved the Australian Warbirds Association Limited to administer aircraft operating under the Limited Category.

Strikemaster Inquest Update

The New South Wales Deputy State Coroner recently released findings into a 2006 fatal Strikemaster aircraft crash near Bathurst, NSW (Coroners Findings). Some of the findings relate to safety issues raised by the ATSB in its report released on 9 May 2008 (

These issues cover:

• Inspection procedures for detecting cracking in the bore of a wing lug
• The transfer of an aircrafts systems of maintenance from the military to the civil environment.

Circumstances of the accident

On 6 October 2006 a BAC 167 Strikemaster broke up mid-flight with two people on board. The pilot was taking the passenger on an adventure flight which was intended to include high level aerobatics followed by a low-level simulated strike mission.

The majority of the available evidence was consistent with a break-up initiated by separation of the tail surfaces leading to the separation of a weakened right wing. The right wing had been weakened by fatigue cracking in the wings upper main spar attachment lug. Although the fatigue cracking was found not to have contributed to the initiation of the aircrafts break-up, the fact its presence was not picked up during maintenance checks underpinned the safety issues raised by the ATSB.

The Coroner reached the same finding as the ATSB as to how the aircraft broke up mid-flight. A number of the Coroners recommendations arose out of the safety issues identified by the ATSB.

Safety Issues

Inspection Procedures for Detecting Cracking in the Bore of a Wing Lug

The right-wing main spar upper attachment lug contained two pre-existing fatigue cracks that had not been detected.

Related to this finding the Coroner issued a recommendation to CASA that consideration be given to amending a servicing procedure instruction so that in preparation for non-destructive eddy current testing, the area for such testing is to have all coatings removed.

Transfer of an aircrafts systems of maintenance from the military to the civil environment

The Strikemaster aircraft involved in the accident was delivered new from the British Aircraft Corporation to the Republic of Singapore Air Force in 1970. It was retired from military operation in 1986. When it was brought out to Australia it was originally utilised for aerial and static displays at airshows before being used for adventure flights.

The ATSB raised a safety issue that the transfer of aircraft systems of maintenance from the military to the civil environment has the potential to reduce the level of safety, due to the probability of incomplete documentation and a lack of specialist aircraft type knowledge. In its report the ATSB noted that there is no certainty by which a civil owner of a military aircraft can obtain information from the military aircraft manufacturer or previous military owner.

Although there are currently no known Strikemaster aircraft flying in Australia, the safety issue was to be considered in relation to ex-military aircraft more generally.

Following the accident, CASA gave approval to the Australian Warbirds Association Limited (AWAL) to administer aircraft in the Limited Category. This was considered to be a positive action to advance safety. The aircraft must be operated and maintained in accordance with the AWAL manual or have a specific approval issued by CASA. In his findings the Coroner reviewed some of the progress with respect to implementing the administration arrangements involving AWAL.

The Coroner also addressed a concern that arose during the inquest about whether a penalty factor was supposed to be applied to the fatigue life of the aircraft. The ATSB raised this matter in its investigation report. After further inquiries made of the manufacturer during the inquest, the continuing lack of certainty led to CASA issuing Airworthiness Bulletin (AWB 02-041: issue 3), recommending registered operators and maintenance organisations review their aircrafts fatigue index records and determine if the penalty should be applied.

The Coroner has sought further action in relation to the issue of the availability of information from manufacturers of military aircraft to persons operating them in the civil environment. The Coroner made a recommendation that every year CASA contact manufacturers of military aircraft and other limited category aircraft seeking any new information that relates to the safe life and operation of the aircraft.

Other Recommendations of the Coroner

The ATSBs investigation focussed on factors leading to the occurrence of the accident. The Coronial inquest looked at these factors but also at matters affecting the search and rescue response which resulted in a number of findings and recommendations. These included recommendations with respect to the carriage of Emergency Locator Beacons and Emergency Position Indicating Radio Beacons. The Coroners report should be referred to for these to ensure that they are understood in the context of the evidence at the inquest.

ATSB Investigations and Coronial Inquiries

Inquests are separate to ATSB investigations. The Coroner formulated his findings and recommendations independently of the ATSB. The ATSB cannot speak for the Coroners findings. However, the ATSB supports the coronial process and in the interests of ensuring that safety information is made available to the broadest audience the ATSB is making this publication.

The NSW Coroners report can be obtained via the Coroners Court website. Queries regarding the Coroners findings should be directed to the Coroners Court of New South Wales.

The ATSB's report can be downloaded from the link at the top right of this page.