Summary

At 2300 hours on 16 November, the German flag container ship Columbus Victoria anchored in Port Phillip Bay with Point Gellibrand bearing 353 x 1.75 miles. The vessel anchored to the port anchor with 5 shackles on deck in about 12 m of water. The ship's draught was 6.3 m forward and 7.25 m aft. Sea watches were maintained on the bridge and the engine was put on 20 minutes notice. The ship was due to berth at about 0600 on 18 November.

At 1220 on 17 November, the chemical tanker Sampet Hope anchored with Point Gellibrand bearing 346 x 1.35 miles. The anchor position was about 4.5 cables north and east of Columbus Victoria. The tanker had a cargo of non-volatile (kerosene type) solvent in four centre tanks. The weather at this time was fair with a south-south-west to south-west wind at about 8 knots. Sea watches were maintained on the bridge and the engine was left on instant (3-4 minutes) readiness.

From about 1400 on 17 November, the wind backed and increased in strength. At 1800, the wind speed was recorded at the Harbour Control Centre as west of south at 17-25 knots. By 2200, the wind was noted as southerly at 21-31 knots, gusting to 35 knots, with rain. The sea at the anchorage was described as 'short and choppy'.

At about 2215, the officer of the watch aboard 'Columbus Victoria' detected the ship was dragging anchor, the Master was called, and the engine room given notice that the engine was required.

At about 2220, the officer of the watch on Sampet Hope realised that Columbus Victoria was dragging anchor and that risk of collision existed. He called the Master and at 2226 the engine was ordered. At about 2230, crew members of 'Sampet Hope' were deploying fenders as the container ship approached. The engine and bow thrust were ready for use.

At a time put at between 2232 and 2233, the two vessels collided. The initial impact was taken forward of the tanker's collision bulkhead, on the bulbous bow and the flare of the starboard bow. At about this time 'Columbus Victoria' let go the other anchor, but it did not arrest the drift.

A second impact occurred at 2236. By using the bow thrust, engine and rudder, Sampet Hope cleared Columbus Victoria at 2240 and the tanker weighed anchor at 2252 and the master repositioned the ship.

At about 2240, the engine on Columbus Victoria was ready for manoeuvring. At 2250, the vessel started to manoeuvre and weighed anchor at 2305, re-anchoring at 2330 with 7 shackles in the water to the south of its original position.

Conclusions

These conclusions identify the different factors contributing to the incident and should not be read as apportioning liability or blame to any particular individual or organisation. The following factors are considered to have contributed to the collision between Columbus Victoria and Sampet Hope.

1. The Master and Officers on Columbus Victoria took insufficient account of the increase in wind strength and the likelihood that pronounced yawing could trip the anchor out of its holding ground.

2. The time required to prepare the Columbus Victoria's engine for manoeuvring was excessive in the circumstances and the engine should have been ready for immediate use.

3. The 2000 anchor position did not appear to cause concern to the watchkeepers on Columbus Victoria and any ambiguity between the 2000 position and other positions plotted on the chart was not resolved.

4. The lack of decision to move the vessel at 2000 when the Master of Columbus Victoria voiced his annoyance at Sampet Hope's position, when the distance between the two ships had apparently reduced from 0.5 miles to 0.3 miles.

The Inspector further considers:

5. The Master, officer of the watch and crew of Sampet Hope reacted promptly to the emergency and did all that was possible to avert the collision.

6. The anchors on Sampet Hope are apparently not arranged so that they can be slipped in an emergency.

Summary

On the morning of Saturday 19 October 1996, the Antigua and Barbuda flag cargo vessel Karin B entered Corner Basin, Victoria, bound for Esso Australia Limited's private terminal at Barry Beach, where it was to discharge sections of a new drilling rig. Outside the bar, off Corner Inlet, the wind was very fresh from the north-west, but it eased to about 15 knots as the vessel passed through the inlet. Although the sky was threatening and a frontal change forecast, those on the bridge considered they had time to berth the vessel before the front arrived.

While making the turn from Toora Channel into the dredged Barry Beach Channel, Karin B was caught by a sudden increase in wind and was blown on to the mud bank to the starboard side of the dredged channel. The vessel listed 18 to port before stabilising and was towed off the bank during the next flooding tide by the supply vessel Lady Valesia.

No damage was sustained by the vessel and no pollution occurred.

There is no pilotage at Corner Basin, but in compliance with a Gippsland Ports Authority requirement, an offshore supply vessel master, with local knowledge of Corner Basin and Barry Beach Terminal, was engaged to provide advice to the Master of Karin B.

Conclusions

These conclusions identify the different factors contributing to the incident and should not be read as apportioning blame or liability to any particular organisation or individual.

Karin B was caught by a sudden strong wind associated with the passing of a cold front during the manoeuvre into the confined approach channel to Barry Beach Terminal.

The following factors are considered to have contributed to the incident:

1. Inadequate strategic and operational planning, in particular in the consideration, by all parties involved, of the safety case and the determination of safety parameters and precautions to be taken for the berthing operations.
2. The function of the offshore supply vessel master was not clearly defined so as to be fully understood by all parties involved.
3. The loose use of the term "pilot", which misled the ship's Master as to the situation at Corner Basin.
4. Readily available, up to date information on the approaching front was not obtained from the Bureau of Meteorology.
5. A perceived need, on the part of the Adviser, to get the job done, which would have affected the level of caution adopted.
6. A lack of communication and co-ordination between the two principal companies, which resulted in the vessel being misinformed.

After taking off on an aerial agriculture flight, the aircraft was observed to turn left at low altitude and dump the load. The left wing continued to drop and the aircraft collided with the ground.

Witnesses observed the aircraft at a height of approximately 200 ft soon after take-off from a local grass strip. The aircraft did not gain height and entered a steep nose-high attitude before apparently stalling. The aircraft then pitched down steeply and collided heavily with the ground. The aircraft was subsequently engulfed by fire. The pilot and two passengers sustained fatal injuries.

The pilot of an aircraft reported that a second aircraft (which was travelling in company) was making a forced landing. He reported a rough running engine and severe vibration. Both aircraft were above broken cloud at the time and were having difficulties finding a clear hole to descend through.

A helicopter found the wreckage near last light on the third day of the search. The aircraft had impacted the ground in a 70-degree dive among trees.

FACTUAL INFORMATION

The pilot had arrived at the property to commence spraying operations on the day before the accident and had been provided with a map of the area by the property owner. In addition, the property owner briefed the pilot on the location of relevant powerlines and other obstructions. However, the pilot did not carry out any spraying on that day, but instead flew the aircraft to Scone, in order to have a minor engine problem rectified. He then flew to Mudgee where the aircraft remained overnight.

The pilot returned to the area the next morning, arriving on site at about 0645 ESuT. After spraying approximately 175 acres on an adjoining farm, he commenced an aerial inspection of the next property to be treated but declined an offer by the property owner to accompany him in the aircraft so the property boundaries and powerlines could be pointed out. The aircraft was seen to make three passes over the area before it descended in an easterly direction, toward a crop of barley. A gentle rise, which included a dam bank located at the corner of the crop, had to be negotiated in order for the pilot to position the aircraft at the correct operating height for the swath run. A spurline, suspended over the crop and running in a northerly direction, was located a further 40 m beyond the dam.  A witness reported that the aircraft had appeared to be maintaining level flight, and had commenced spraying, when it struck the spurline, then impacted heavily with the ground and overturned, fatally injuring the pilot. The weather in the area at the time of the accident was reported as fine, with light winds.

The aircraft struck a three-wire spurline which ran in a northerly direction over the crop, at right angles to its flight path. The line spanned 165 m from the main powerline to the first spurline pole, located about 100 m from a house and to the left of the flight path. A number of large trees nearer to the house provided a backdrop to the spurline pole. A strainer wire stemming from the main powerline was positioned some 92 m further on in the direction of the intended flight path. It was about 10 m in length and ran parallel to the spurline. The strainer wire passed over a road and was attached to a support pole located one metre from the edge of the barley crop. The pilot had commenced the first swathe run by flying in an easterly direction, towards distant rising ground which was cloaked in shadow, whilst the powerline in the foreground was set against this backdrop.

The aircraft was an Airparts New Zealand Fletcher FU-24/A4, fitted with a Lycoming 10-720, 400 hp engine and a three bladed, constant speed Hartzell propeller. Such aircraft are used widely in New Zealand, and to a lesser extent in Australia, principally for agricultural operations. Although they are most often used for the aerial spreading of solids onto crops and pastures, this particular aircraft could be equipped for spreading or spraying. The hopper had just been refilled prior to the pilot's aerial inspection and was believed to contain about 1000 kg of a non-toxic spray medium. The spray equipment fitted to the aircraft consisted of booms with standard spray nozzles, and a wind-driven spray pump. Depending on the conditions, spraying with this equipment generally required the aircraft be flown with the spray nozzles at a maximum height of 6-10 ft above the crop. At the time of the accident the aircraft was being operated at or near its maximum weight. The aircraft was not fitted with wire deflectors or cutters.

An on-site examination of the wreckage revealed that the powerline had removed the cockpit canopy before slicing off a major portion of the vertical fin. The aircraft then continued forward a further 90 m, before it collided with the ground and overturned. The design of the aircraft provided limited rollover protection, with the result that the upper cockpit area was grossly disrupted.

Given the position at which the spurline wires had sliced through the vertical fin, it was calculated that the aircraft was flying some 8-10 ft higher than the normal spraying height. There was no evidence found of any condition which may have affected the normal operation of the aircraft.

The pilot held a valid licence for the operation being undertaken. He had accumulated some 7,200 flying hours, of which 5,500 hours had been flown in helicopters. Of the 1,700 hours of fixed wing flying, some 800 hours was agricultural flying. He had completed a biennial flight review on 2 October 1996 but had not flown any aircraft between 28 April 1991 and 21 August 1996. The pilot had not flown a Fletcher before commencing work for the operator one month prior to the accident flight. He had then flown about 28 hours in the aircraft, with much of that time engaged in the aerial spreading of superphosphate and urea, an operation which is normally carried out at a height of about 200 ft.

Three days before the accident the pilot commenced taking two prescribed medications for diarrhoea and nausea resulting from an intestinal condition. An aviation medical practitioner indicated that the main concern with such a condition is dehydration, possibly exacerbated during the initial days of treatment by the medications. Some of the effects of dehydration are general fatigue, reduced levels of concentration and drowsiness.

ANALYSIS

Aspects of the pilot's experience, his general wellbeing, and the visual cues available to him to locate the position of the spurline, were considered to be significant factors in the development of this accident. Pre-existing aircraft equipment and structural design factors were also considered relevant to the non-survivability of the pilot.

Whilst the pilot had considerable overall flying experience, he had not flown during the previous five years, having only returned to flying about one month prior to the accident. In addition, he had limited experience on the aircraft type, particularly in low-level spraying operations. This would have made it more difficult for the pilot to accurately position the aircraft at its correct operating height for the swathe run, after manoeuvring to negotiate the gentle rise and dam bank.

It is possible that the performance of the pilot may have been somewhat impaired by the effects of his medical condition. This could have included fatigue, reduced levels of concentration and drowsiness, resulting in a momentary lapse in awareness prior to striking the powerline; or he may simply have been unaware of its location.

If the pilot had not located the position of the spurline during his aerial inspection, due to the unobtrusive location of the spurline poles, he may have believed the line was located further along the swathe run due to the more obvious presence of the support pole adjacent to the crop. As a result, he could have considered he had more space in which to descend, in order to pass beneath what he thought were the only powerlines passing over the crop. There would have been little opportunity for the pilot to have seen the line during the approach to the crop. The orientation of the spurline in relation to the flightpath, the lack of contrast available to discern the wires from the background, and the difficulty in locating the poles of the spurline, were factors which support this view.

Damage resulting from the wirestrike may have been reduced or eliminated, had the aircraft been fitted with a suitable wire deflector/cutter system. The installation of such equipment was not required for the operation being conducted. The design of the aircraft provided limited structural rollover protection, and in this occurrence, the degree of disruption to the upper cockpit area made the accident non-survivable, even though the pilot was wearing a protective helmet.  With the canopy already separated from the fuselage, and with no other form of rollover protection, the pilot was exposed to the brunt of the impact forces as the aircraft overturned.

SIGNIFICANT FACTORS

1. The pilot had limited recent flying experience.
2. The pilot had limited experience on the aircraft type, particularly with regard to low-level spraying operations, prior to the accident.
3. The performance of the pilot may have been impaired by the effects of a medical condition he was suffering from.
4. The location of the spurline was difficult to see and may have been confused with an apparent powerline, further along the intended flight path.
5. The aircraft was not fitted with any form of wire deflector or cutter.
6. The aircraft provided limited structural rollover protection for the pilot during the accident sequence.

The task was to spray a paddock which contained two sets of wires. The pilot was aware of the wires and planned to fly under the high-tension wires mounted on pylons, and over the smaller dual set of supply wires. On about the sixth spraying run, and after successfully flying under the high-tension wires, the aircraft was seen to level off in the pull-up manoeuvre and attempt to fly under the second set of wires. The aircraft contacted the wires and descended into the ground. It then bounced up in a fireball and impacted the ground a second time.

When observers arrived at the scene, the aircraft was burning fiercely, and rescue of the pilot was not possible.

The pilot was given a briefing and a map of the area to be sprayed. Both of these included information about the two sets of wires on the property. The pilot told the aircraft owner that he planned to fly under the first set of pylon wires and over the second set of smaller, lower wires. He was seen to orbit the paddock a number of times after arriving in the area and before commencing his first swath run. The pilot operated according to his stated plan for about six runs before he struck the wire.

The pilot was reported to have a safety orientated work ethos and demonstrated a professional approach to his work. His chief pilot had observed him on several occasions when he would have been unaware that he was being watched and, on these occasions, he did not demonstrate any unsafe tendencies.

Studies have been conducted over the years aimed at identifying deficiencies in agricultural operations, in particular, those associated with wire strikes. It is generally accepted within the aviation industry that wires present a constant hazard to agricultural flight operations, and, in this case, the pilot took appropriate actions to minimise the danger to his task. It was not determined why the pilot did not fly over the second set of wires, after successfully clearing them on about six previous occasions. The tolerances in an under and over operation, such as this, are narrow, and small distractions to the pilot's focus on the wires could result in a miscalculation.

No evidence of aircraft or engine malfunction was found in the investigation, nor was any predisposing medical condition identified. The pilot showed no signs of fatigue, and his demonstrated skills were suitable for the task allocated.

The helicopter was spraying chemical over a banana crop when it struck a powerline and heavily impacted the ground. The helicopter caught fire after hitting the ground.

The flight was planned as a one-hour inspection of tourist spots in the Isdell River area, 175 km north-east of Derby. The helicopter departed the base camp at Silent Grove, 15 km south-east of Mount Hart Station, landed once during the flight, and was returning to the base camp when the crash occurred. The crash site was 8 km north of the camp.

All occupants received serious injuries in the crash. One passenger, who appeared to be the most able, walked to the base camp to get help. He arrived there shortly after first light the next day. The wreckage, and the other occupants were found at approximately 1100 on the day after the crash. One passenger died during the night.

FACTUAL INFORMATION

Around lunch time on the day of the accident the pilot invited a number of people for a joy flight later in the day to view whales off the coast near Byron Bay. The flight was expected to take about 45 minutes.

The pilot and one passenger arrived at the aircraft at about 1630 EST, when the owner was repositioning the aircraft in its hangar. The other two passengers arrived about five minutes later. At that time, the pilot was conducting a pre-flight inspection and talking to the aircraft owner. Prior to the pilot completing his inspection, the owner departed. The owner did not note the quality of the pilot's pre-flight inspection, or whether the fuel tanks were tested for water.

The passengers boarded the aircraft and the pilot had them fasten their seatbelts. He then started the engine and taxied to the runway. One passenger considered that the pilot was in a hurry during this period; however, another pilot flying near the strip, and observing the take-off of the aircraft, considered that the aircraft spent an unusually long time at the eastern end of the airstrip. The take-off was towards the west at about 1653.

Witnesses reported that soon after the aircraft became airborne, when at a height of 70 to 100 ft above the strip and with the landing gear almost retracted, the engine rapidly lost power. A passenger reported that the pilot tapped a number of instrument faces, asked himself what was happening a couple of times, and appeared to become panicked. Pilots at the airstrip said that they expected the nose of the aircraft to be lowered but this did not occur. A short time later the wings began to rock before the left wing dropped and the aircraft collided with the ground beside the Pacific Highway. At impact, the aircraft was banked about 90 degrees to the left and was descending at an angle of about 30 degrees. The left wing broke into sections and the aircraft slid backwards to rest against trees beside the road. The four occupants were rescued from the aircraft before it was consumed by fire.  The pilot and the passenger who had been seated in the front seat were fatally injured.

The investigation found that the landing gear and flaps were up, with the left fuel tank selected at impact. The main tanks were reported to be close to full, with the wing tip tanks containing only residual fuel. Water was found in the fuel injection distributor valve on the engine. A small quantity of water was also found in the fuel control unit.

When the aircraft was ferried to Australia about a year before the accident, the ferry pilot noted that water collected in the left fuel tank after rain. The O-ring seals in the fuel caps were recorded as having been changed during maintenance to place the aircraft on the Australian register.

The aircraft had been parked in the open up to a few days prior to the flight and during that time, heavy rain had been experienced at the airstrip. The aircraft had been taxied to the hangar from its previous parking spot, although the owner could not remember which tank had been used. The investigation was unable to determine whether a fuel quality check was conducted prior to this flight.

Information provided by the aircraft manufacturer showed that not all water which entered the fuel tanks would have been extracted by normal fuel drain checks. The residual water remained in the tanks during normal flight manoeuvres but would have the potential to move from the tanks into the fuel lines given the right circumstances.

The pilot had flown from the airstrip on previous occasions, and in the aircraft owner's opinion, was well qualified with about 8,000 hours of flying experience. The owner had flown with the pilot on a number of occasions. Although the pilot held a perpetual Australian private licence for aeroplanes, his medical certificate had expired in July 1994 invalidating the licence.

An emergency locator transmitter (ELT) was fitted to the rear of the passenger compartment.  The owner believed the ELT to be capable of normal operation. The unit was destroyed by the fire and no reports of its activation were received from overflying aircraft.

ANALYSIS

The fuel distributor valve on the engine is the last point in the fuel system before the fuel runs through small pipes into the combustion chamber. Water in this valve would mean that water was being fed to the engine. Depending on the quantity of water in the fuel system, the presence of water would result in rough running or complete engine stoppage. On this occasion the engine stopped.

A suitable forced landing area was available if the aircraft had been landed straight ahead in the direction of the take-off. While the distance available may have been inadequate, it did offer an area suitable for a substantial part of a forced landing.

The aircraft's nose was not lowered from the initial climb attitude, and landing gear and flaps were selected up at impact. This evidence suggests that the pilot did not take appropriate emergency actions intended to control the aircraft after the engine failed.

SIGNIFICANT FACTORS

1. The pilot did not conduct an adequate pre-flight fuel inspection.
2. The engine failed due to water in the fuel system.
3. The pilot did not initiate appropriate actions to carry out a forced landing.
4. The aircraft collided with the ground after it lost flying speed.