FACTUAL INFORMATION

History of the flight

Pylon racing was conducted at Valley Field, south of Launceston, from 14-19 February 1995. Following completion of the races five T-28 aircraft were to be flown back to the mainland from Launceston. The plan was for the T-28s and a PA-31 to return to the mainland in loose formation.   The role of the PA 31 was to provide search-and-rescue support in the event of a T-28 ditching.  On the morning of the accident the formation leader briefed the pilots involved.  Take-off was to be in formation pairs, spaced a short time interval apart.  The first two pairs were to be T-28 aircraft.  The pilot of VH-LAO asked to be in the last pair which meant flying in formation with the accompanying PA-31 aircraft.  The flight was briefed as a normal departure, no mention was made of the performance of any aerobatic manoeuvres, nor did the pilot of VH-LAO discuss this possibility with any of the other formation members.

The formation take-off on runway 32 proceeded as planned with the pairs taking off at 15-20 second intervals.  Due to the performance of the PA-31 being lower than the T-28, the climb speed of the last pair was limited to about 120 knots.  Observers reported that the third pair made a normal take-off and initial climb, with the T-28 to the left of the PA-31.  At a height of about 500-600 feet the nose of VH-LAO was seen to rise and the aircraft started rolling to the left.  The left roll continued with altitude remaining about the same until the aircraft had rolled inverted. At about that stage of the roll, the nose started to drop.  After about 270 degrees of roll, the aircraft's attitude was very nose-low, and the rate of roll had decreased.  Observers indicated the pilot appeared to be trying to recover from the dive, but there was insufficient altitude to regain level flight before the aircraft, still 10-15 degrees nose-down, struck the ground.  Some witnesses thought the engine continued to operate at about the same power as at the start of the manoeuvre, but one person indicated the power was cut while on the final descent.

Damage to aircraft

The aircraft was severely damaged by impact forces and a post-impact fire.

Wreckage trail/wreckage examination

The aircraft struck the ground approximately 100 metres to the left of the extended runway centreline.  The wreckage trail, which extended for about 140 metres, was towards the north-east (about 90 degrees to the right of the take-off path).  The landing gear and flaps were in the retracted position. Examination of the wreckage did not identify any evidence of a pre-impact defect that could have affected the safe operation of the aircraft.  Also, nothing was found that could have caused an uncommanded roll to the left.

Weight and balance

At the time of take-off, the aircraft was loaded to approximately the maximum permissible take-off weight.  Balance was within limits.

Passenger background

The passenger did not have any pilot qualifications.

Pilot history

During 1986 the pilot had completed part of an RAAF pilot course.  He was suspended from this course following unapproved low flying manoeuvres.  Subsequently he took up civilian flying.  At the time of the crash, he held a Grade One fixed wing instructor rating.  In October 1989 he had received an endorsement to conduct basic aerobatic manoeuvres.  At about the same time he also received an endorsement authorising him to teach basic aerobatic manoeuvres, including loops, aileron rolls, slow rolls and barrel rolls.

After obtaining his aerobatic approvals, his logbook showed he had done only a moderate amount of basic aerobatic flying and aerobatic instruction.  Most of this was in simple general aviation type aircraft such as the Cessna 150. These types are small and light and have a very moderate performance compared to the much heavier, higher powered and faster T-28. The pilot did not hold an approval to conduct aerobatic manoeuvres below 3,000 feet.

Reports indicated that during his time as an instructor he had occasionally been involved in abnormal flight activities.  These included continuing flight into poor weather conditions and making multiple very low passes over a country airstrip.  On two separate occasions with student pilots, he had taken the controls and conducted a 360-degree roll manoeuvre.  The aircraft type on which these manoeuvres were flown was not approved to perform aerobatic manoeuvres.  For approximately the last two years the pilot had been employed as a co-pilot on regular public transport operations, but he still maintained an active interest in private flying.

The pilot obtained a T-28 endorsement on 2 April 1994.  During the endorsement he carried out two or three horizontal roll manoeuvres. These were executed from an entry speed of 180 knots, the normal speed for entering such rolls.  A few days later a flight included horizontal roll manoeuvres, using entry speeds of about 190 knots. The pilot did not fly the T-28 again until 12 February 1995, when he did a short flight with the owner of another T-28.  On 15 February he was permitted to fly this T-28 to Launceston with the owner-pilot on board.

At Valley Field the pilot received a low-level check required by the organisers for participants in pylon races.  This check was only for pylon racing and did not include any aerobatic manoeuvres. While at Valley Field, he was trained to fly the pace plane used to start aircraft in the T-28 pylon races. The pilot did not fly in pylon race events but did fly the pace plane on four or five occasions.  The pace plane leads the competitors to the start line and then pulls up out of the way.

The pylon races were conducted at a minimum height of 200 feet, but competitors were permitted to descend to 100 feet on the straight leg.  The races ended on the straight, at which stage the aircraft were at relatively high speeds. At the end of the race a pull up/climb manoeuvre was required, to a height of 2,000 feet.  While doing this pull up/climb, some competitors executed a 360-degree roll manoeuvre.

On one occasion at Valley Field the pilot, while flying a T-28, was observed to carry out a barrel roll aerobatic manoeuvre at a height of about 1,500 feet.  On the day prior to the accident, he flew as a passenger-observer in a T-28 flown by a well-known American air-show pilot, who conducted an impressive low-level aerobatic display.

Medical information

The pilot passed his last pilot licence medical examination on 18 April 1994.  Following the accident a post-mortem examination was performed on both the pilot and the passenger.  No evidence was found to indicate that either the pilot or the passenger had any medical condition that might have contributed to the accident.

Meteorological information

Information from the Bureau of Meteorology indicated that at about the time of the accident the weather was fine. The temperature was about 19 degrees, the surface wind was from 270 degrees at three knots and there were five octas of cumulus cloud with a base of 3,500 feet.  There was no significant turbulence.

Wake turbulence

The only possibility of wake turbulence would have been from the preceding T-28 aircraft, but this could not have caused the manoeuvre flown.

Survival aspects

The accident was not survivable.

Tests

The normal entry speed for roll manoeuvres in the T-28 was about 180 knots.  The speed at the time of the roll that preceded the accident was probably about 120 knots.  Information was sought on the roll capability at the slower speed, and limited testing was done by an experienced competition aerobatic pilot who also owned a T-28.  The aircraft was loaded to a similar weight.  Tests showed that an aileron roll could be completed without losing significant altitude.

Barrel rolls to the left were attempted but in every case the recovery occurred with a 60-70 degree deviation to the right.  The testing pilot used different methods of entry for these manoeuvres.   Significant altitude losses could not be avoided and were approximately 600-800 feet.  On one of the rolls the throttle was closed about two-thirds of the way through the roll. This resulted in an additional altitude loss of about 200 feet.

ANALYSIS

The weather conditions were good.  The only wake turbulence that could possibly have been encountered was from preceding aircraft, which were of the same type.  This could not have caused an upset of this magnitude.  No evidence was found to suggest any abnormality existed with the aircraft.  There was no evidence to suggest that anyone, apart from the pilot, had any idea that an aerobatic manoeuvre might be conducted after take-off.

Evidence indicated that on occasions the pilot had carried out unapproved flying activities. The information indicated a strong probability that on the accident flight the pilot had attempted to carry out a low altitude roll manoeuvre.  He was not approved to do low-level aerobatics, and his background training did not prepare him for such manoeuvres.  He had little experience on the T-28, which is a large, heavy, high powered, single engine aircraft type.  From the evidence, it appears that the pilot was attempting a roll manoeuvre and mishandled the aircraft.  The high degree of hazard associated with attempting such a manoeuvre at such a low height was significantly increased by the relatively low airspeed at which it was started.

CONCLUSIONS

Findings

1. The pilot was correctly licensed and endorsed to fly the T-28.
2. The pilot held an aerobatic endorsement but did not hold an approval to conduct aerobatic manouevres below3,000 feet.
3. The pilot had a moderate level of basic aerobatic experience and had little aerobatic experience on the T-28.
4. The weather conditions were good and did not contribute to the accident.
5. There was no evidence of any defect in the aircraft.
6. There was no evidence to show that anyone apart from the pilot had any idea that an aerobatic manoeuvre would be performed after take-off.
7. The evidence indicated that the manoeuvre carried out was intentionally initiated by the pilot.
8. The relatively low airspeed at the start of the manoeuvre was well below that recommended for the conduct of horizontal rolls.

Significant Factors

1. The pilot had limited experience on the aircraft type and had never been trained for, or approved to do, low-level aerobatic flight on any type.
2. The pilot probably attempted to carry out an aerobatic manoeuvre at an unsafe height.

Factual Information

History of the flight

The purpose of the flight was to attend air races near Launceston. The flight had been planned for some weeks and had been the subject of discussion between the pilot, his wife, professional colleagues and local aero club members. Aspects discussed included the route and altitude to be flown. It was the understanding of those involved in the discussions that the pilot intended to conduct the flight under the instrument flight rules (IFR).

On the day of the flight, the weather at Port Macquarie was reported by witnesses to have been overcast with a cloud base about 400 ft above ground level (AGL) and intermittent rain.

A male passenger, who held a restricted private pilot licence and had limited flying experience, assisted the pilot in loading the aircraft. The pilot told him that he intended flying in accordance with the visual flight rules (VFR) coastal to Nowra and, if there were any delays in obtaining clearance through the Nowra restricted area, he would proceed IFR inland. However, the pilot stated that he had been told that the weather improved further south.

The pilot invited the male passenger to occupy the front right seat. The female passenger occupied the left rear seat, and the pilot's wife, who also had limited flying experience gained some years previously, the right rear seat. The male passenger secured his sash harness and noticed that the pilot fastened his lap harness only.

The male passenger reported that as soon as the pilot had retracted the landing gear after take-off, he motioned for the male passenger to take control and fly the aircraft. The passenger placed his hands on the control yoke and the pilot then told him to turn towards the coast and to remain below the cloud. The passenger recalled the aircraft reaching the coast at Lake Cathie (about 13 km south of Port Macquarie Airport) and noticed that the altimeter was reading about 300 ft. He then turned the aircraft right to track south along the coast. The cloud was unbroken overcast, and the aircraft was just below the cloud base.

A few kilometres further south, the aircraft overflew a built-up area near the coast and the pilot's wife commented that the aircraft was too low. The pilot then placed his hands on the control yoke and the male passenger removed his hands, assuming the pilot was taking control of the aircraft, even though nothing was said. A short time later, the female passenger saw the pilot's wife release her seat harness and lean across, in a semi-standing position, to again say to the pilot that the aircraft was too low. The male passenger recalled at this time, that the aircraft was heading for Diamond Head, and that the top of the hill was shrouded in cloud. He could see the ocean to the left of the aircraft and expected the pilot to turn in that direction. However, the pilot continued straight ahead and did not appear in any way concerned as to the progress of the flight. The male passenger indicated that he was tempted to try to take control of the aircraft but was convinced not to do so by the pilot's demeanour and his knowledge of the pilot's flying experience. The last clear recollection the male passenger had of the flight was seeing trees 10 m or so below the aircraft. Sometime later, he regained consciousness and extricated himself from the wreckage. The female passenger was trapped in the wreckage and later released by rescue services.

The aircraft had struck the slope of a 60 m high hill, bounced, and come to rest about 100 m from the initial impact point in an area of thick trees at the top of the hill.

Pilot information

The pilot held a valid private pilot licence and command multi-engine instrument rating.

The pilot's logbook showed that he began flying in 1978, although he may have had some experience prior to this. Of the total flying time of 2,348 hours recorded, 840 were in Beech Baron type aircraft. Some 10 flying hours were recorded as having been flown in the past 90 days, and 2 hours in the past 30 days.

Aircraft information

The aircraft was purchased by the pilot in the USA and brought to Australia in mid to late 1989 carrying US registration N9124S. It retained this registration at the time of the accident.

The most recent entries in the airframe and engine logbooks for the aircraft were for an annual inspection dated 26 October 1990, carried out in Australia. Some records of maintenance work carried out on the aircraft since then were located. This work did not conform to any maintenance schedule for the aircraft but was directed on an ad hoc basis by the owner. There was no record found of regular maintenance, such as 100-hourly inspections having been conducted nor was there any record of maintenance conducted in accordance with the US Federal Aviation Administration (FAA) system. The pilot's logbook indicated that since October 1990 he had flown in excess of 500 hours in N9124S.

No record was found of the following US FAA airworthiness directives having been complied with on the aircraft:

1. AD 90-08-14 requires the inspection of the wing forward spar carry-through web structure every 500 flight hours. The most recent record of this inspection being performed was in October 1990.
2. AD 91-17-01, issued on 25 October 1991, was to prevent loss of control of the aircraft because of interchanging the right and left elevator trim tab actuators. There was no record of this inspection having been complied with.

There was also no record of any flight or navigation instrument having been calibrated after 26 October 1990.

Meteorological information

The Bureau of Meteorology advised that at 1000 on 17 February 1995, a cold front extended north through the Tasman Sea from a deep low-pressure system south of Tasmania. The front had progressed along the coastal regions of NSW and was in the vicinity of Yamba at 1037. A deep, moist, southerly airstream was flowing on to the coastal regions causing low cloud and rain showers.

The estimated conditions in the area of the accident were as follows: wind 140/08 kts, showers and rain throughout the area, overcast stratus/cumulus base 200 ft above sea level, visibility 10 km reducing to 1,500 m in showers and rain, temperature 27 degrees C, barometric pressure 1011 hPa.

The Area 20 (including from Port Macquarie to Sydney) amended forecast, issued at 0934 and covering the period of the flight, was for scattered showers and drizzle about the sea, coast and ranges with areas of low cloud east of the ranges and in precipitation. The Area 21 (including Sydney south to Moruya) amended forecast issued at 0926, and covering the period of the flight, was for low cloud with showers persisting coastal and east of the ranges.

There was no record of the pilot having accessed the Aviation Meteorological and NOTAM Facsimile Service (AVFAX) in the period 14-17 February 1995. It was not determined whether the pilot accessed the Automatic Meteorological Telephone Briefing Service (DECTALK) prior to the flight.

Witnesses at a campsite at the base of the hill struck by the aircraft reported that the top of the hill was obscured by cloud at the time of the accident.

Communications

An examination of the Air Traffic Services automatic voice recording of air-ground communications covering the period of the flight did not reveal any radio transmissions from N9124S.

An AVDATA logging recorder is located at Port Macquarie Airport to record aircraft transmissions made on the local mandatory traffic advisory frequency (MTAF) for the purpose of levying charges on aircraft operating to or from the airport. The recording covering the period of the flight of N9124S was examined. However, no transmissions that could be identified as originating from N9124S were detected.

Wreckage and impact information

The aircraft struck the western slope of a ridge 2.2 km west of Diamond Head at a height of about 50 m above mean sea level (AMSL) while heading in a south-easterly direction and in a very shallow descent. The impact position was some 13 m below the top of the hill. The aircraft bounced from the initial impact position and contacted the ground again 45 m further on, before sliding 60 m into an area of dense scrub. The aircraft remained upright throughout the sequence.

Wreckage examination revealed that the outboard wing sections had failed and that both engines were torn from their mounts. The remainder of the aircraft was relatively intact.  The landing gear was in the retracted position. The flaps were extended approximately 16 degrees although the position selector was in the 'up' position and the position indicator showed fully up. The cabin floor was partially disrupted, but all seats remained attached to the seat rails. There were no seat belt failures.

The airspeed indicator, encoding altimeter, vertical speed indicator, auto-pilot turn co-ordinator, instrument air gauge, attitude gyro, pictorial navigation indicator, remote slaved directional gyro, course select indicator, radio magnetic indicator, both vacuum pumps and their associated filters and regulators, were removed from the aircraft and tested.  All components met test specifications except the following.

1. Pictorial navigation indicator. This instrument was damaged in the accident and tested inoperative because of a missing cable connector pin in connector P1 on the rear of the instrument. There was evidence that some attempt had been made in the past to repair the pin. Impact damage had caused the drive gears on the heading bug to be disconnected. The operational status of the instrument before impact was not determined.
2. Remote slaved directional gyro. This instrument showed evidence of moisture ingress. The rotor housing gimbal assembly was out of position and all rotor bearings were unserviceable at the time of the inspection. The operational status of the instrument before impact was not determined.
3. VOR/localiser indicator/converter. This instrument was visually undamaged. However, bench tests revealed that the unit was out of tolerance on most radials, with errors of up to 6 degrees (the tolerance is 2 degrees for aircraft certified for instrument flight). These errors were probably present before impact.

The encoding altimeter was indicating 160 ft in the aircraft wreckage, with the subscale set at 1011 hPa.

At the initial impact position, there were a number of distinct propeller blade tip marks on the ground. The distance between the marks for both the left and right propellers was one metre.  At an engine cruise RPM of 2,200, this distance between blade marks equates to an aircraft speed of 143 kts.

The aircraft was fitted with a Narco ELT 10 Locator Beacon which was recovered from the wreckage undamaged, with the switch in the armed position. The beacon had not activated during the impact sequence. The battery change date written on the unit was 28 September 1992. Examination of the beacon revealed that the g-switch had been activated and that the battery voltage was at the required level. The beacon was functionally tested and performed normally.

Medical information

There was no evidence that the pilot had any medical condition which might have contributed to the accident.

Survival aspects

The pilot died from head injuries received when his upper body was thrown forward against the instrument panel, probably at the initial impact. The pilot's wife was ejected from the aircraft during the impact sequence and died of multiple injuries.

The male passenger occupying the front right seat had his lap/sash harness secured during the flight. He received serious back injuries from the impact but was able to extricate himself from the wreckage unaided. The surviving female passenger had her lap belt secured for the flight. She received serious back injuries and was removed from the wreckage by rescue personnel.

Pilot's instrument flying history

The pilot had recorded a total instrument flying time of 242 hours. However, there was no record of instrument flying (other than instrument rating renewals, and practice for these renewals) after November 1992.  The recorded yearly total, and instrument, flying hours since November 1992 were as follows:

Period Total Flying Hours Instrument Flying Hours

Pilot's flying history - other aspects

On 1 January 1990, at 2120, the pilot was the subject of an air safety incident report concerning a flight from

Maitland to Bankstown in N9124S.  The aircraft penetrated controlled airspace between 9 and 15 NM north of Sydney Airport and was involved in a breakdown in separation with a regular public transport aircraft on approach to Sydney.  The pilot had departed Maitland without having obtained weather forecasts and attempted to fly the route visually at night. Weather conditions were poor with Bankstown Airport closed to all operations. Flight service had no information on the aircraft and the pilot's first radio communications with any unit was when he contacted Bankstown Tower.  The aircraft subsequently landed at Bankstown.

There was some anecdotal evidence obtained during the investigation concerning the pilot's flying habits which was relevant to the circumstances of this accident:

1. It was reported that the pilot had flown into Bankstown visually on a number of occasions when the weather was not suitable for visual flight.
2. It was reported that N9124S, when flown by this pilot, was one of a group of aircraft which flew from Bankstown to Lord Howe Island and return. The pilot conducted the flights visually at 2000 ft, while all other aircraft in the group flew in accordance with IFR procedures at 8,000 to 10,000 ft.

Flight planning

The Civil Aviation Authority held no flight plan information on the aircraft. The male passenger indicated that he did not see any flight planning information, such as a pilot flight plan or map or chart held or consulted by the pilot at any stage during the flight.

Several maps and charts were found in and around the wreckage. These included departures and approach procedures charts, visual terminal charts (VTC) for Sydney/Newcastle and Hobart/Launceston, Enroute Charts Low L3 and L4, a terminal area chart folded at Launceston, and some blank flight plan forms. The Hobart/Launceston VTC was open at Launceston and some prominent features on the chart were circled. On the back of another chart were handwritten altitude minima and frequencies for the Launceston navigation aids.

Aircraft registration history

In September 1991, the pilot, as owner of the aircraft, wrote to the FAA requesting that the aircraft be removed from the US register (this was a pre-requisite for Australian registration). Included in this letter was advice that legal action against the vendor had been initiated for, amongst other things, a bill of sale to be issued. In response, the FAA advised that ownership issues had to be resolved before registration could be cancelled. A representative of the pilot advised, after the accident, that the legal action was concluded in late 1994 in favour of the pilot.

Visual flight rules (VFR)

The Aeronautical Information Publication Australia (AIP), RAC - 23, lists the visual flight rules (VFR). It states that VFR flight may only be conducted in visual meteorological conditions (VMC). VMC - take-off, en route, and landing, in non-controlled airspace, for aeroplanes - is described at AIP RAC - 25 as follows:

1. For an aircraft flying at or below 3,000 ft AMSL or 1,000 ft above terrain, whichever is the higher,
2. Visibility - 5,000 m, and
3. Clear of cloud.

No evidence was found that the pilot had received a low-flying endorsement or any low flying training.

Analysis

The actual weather at Port Macquarie and the weather forecasts indicated that the weather was not suitable for flight under the VFR. The official weather information did not indicate that the weather improved to the south, as the pilot was reported to have indicated to the male passenger. While it was established that the pilot had not accessed the AVFAX system for a weather forecast, he may have obtained weather information by telephone (DECTALK or some other source). While the DECTALK information would have been the same as that from AVFAX, another source could have provided different information which encouraged the pilot to undertake the flight.

The fact that the weather conditions did not meet the criteria for flight under the VFR was not, in itself, a factor in the accident. However, it is self-evident that the lower the cloud base, the higher the skill level required to fly and navigate an aircraft safely below the cloud. Information from the male passenger and ground witnesses confirmed that the aircraft was flying very low just below the cloud base throughout the flight. It appears likely that the cloud base became progressively lower as the flight continued, being around 300 ft when the aircraft first crossed the coast, and decreasing to about 160 ft where the accident occurred. There was evidence that the pilot had operated in marginal weather conditions previously and reached his destination. This may have given him confidence that he could successfully undertake the accident flight.

No explanation was found as to why the pilot, on the one hand, maintained an instrument rating and indicated his intention to conduct the flight under the IFR, while in the event attempted to conduct the flight visually.  The fact that the pilot did not submit a flight plan for the flight indicated that he did not intend to conduct the flight under the IFR.

A safe option available at any stage during the flight was for the pilot to place the aircraft in a climb towards the east (over the ocean), and request assistance from flight service or air traffic control. There was no evidence that the pilot attempted this course of action.

The impact attitude and angle of the aircraft indicates that no attempt was made to avoid the rising ground. It could not be established whether the pilot was aware of the rising ground ahead of the aircraft.

Both the pilot and his wife received injuries directly attributable to their manner of restraint within the aircraft cabin. In view of the extent of the injuries to the surviving passengers, it is likely that the pilot and his wife would have survived the accident had the pilot's shoulder harness, and his wife's lap harness, been secured.

There was no indication that the aircraft was not capable of normal flight under visual conditions at the time of the accident. Although some abnormalities were identified with respect to the aircraft registration, maintenance history, and instruments, these are not considered relevant to the circumstances of the accident. There was no indication that any aircraft abnormality influenced the pilot's decision to attempt the flight in visual conditions below cloud.

The position of the flaps in the aircraft wreckage indicated that the pilot was operating the aircraft with the flaps in the approach position. This would have allowed the pilot to operate the aircraft in the speed range 122-153 kts while maintaining good manoeuvrability. The calculated aircraft speed at impact of 143 kts, based on cruise engine RPM of 2,200 and the measured distance between the propeller blades' marks on the ground, fell within the approach flap speed range.

Findings

1. The pilot held a valid pilot licence and was endorsed on the aircraft type.
2. The pilot held a valid command multi-engine instrument rating.
3. The aircraft was purchased by the pilot in mid-1989 and entered Australia carrying US registration N9124Swhich it retained at the time of the accident.
4. There was no record of the aircraft being maintained in accordance with either the US or Australian requirements after an annual maintenance inspection conducted in Australia on 26 October 1990.
5. The coastal weather at, and to the south of, the departure airport consisted of low cloud and showers.
6. It could not be determined whether the pilot obtained any actual or forecast weather information prior to the flight.
7. No record was found of the pilot making any radio transmissions before or during the flight.
8. When the aircraft departed Port Macquarie, it tracked to the coast and thence south, remaining below the cloud base.
9. The aircraft struck the western slope of a ridge 2.2 km west of Diamond Head at a height of about 50 m above mean sea level while heading in a south-easterly direction and in a very shallow, wings-level descent.
10. At impact, the aircraft landing gear was retracted and the flaps extended approximately 16 degrees.
11. Aircraft speed at impact was in the range of 122-153 kt.
12. The pilot did not have his shoulder harness secured at impact.
13. The pilot's wife did not have her seat belt secured at impact.
14. The accident was survivable.

Significant factors

1. The weather along the intended route was not suitable for visual flight.
2. The pilot attempted to conduct the flight visually below cloud.
3. The pilot did not maintain separation from rising terrain.

Safety Action

As a result of the investigation, the Bureau of Air Safety Investigation made the following interim recommendation.

IR950205

The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority:

1. require importers of foreign-registered aircraft to obtain Australian registration for such aircraft within a finite period of the aircraft arriving in Australia; and
2. require airworthiness surveillance of privately operated foreign-registered aircraft to ensure compliance with minimum maintenance inspection requirements.

The Civil Aviation Safety Authority response to the interim recommendation is reprinted below.

I refer to your interim recommendation number IR 950205 concerning the accident involving Beech 95-B55, N9124S on 17 February 1995.

Summary

The recommendation is not accepted insofar as it would not prevent a similar act of non-compliance. There is little to be gained by placing a limit on the period that a foreign registered aircraft may be operated privately in Australia. The real question is the extent of surveillance and enforcement action that CASA should devote to private operations. At present, private operations are not addressed in Part 5 of the Policy Manual which specifies the Director's 1995/96 National Surveillance Priorities.

Response classification: Open

Summary

The Turkish flag bulk carrier M Nuri Cerrahoglu, sailed from Hay Point on 2 November 1994, loaded with about 52,500 tonnes of coal, bound for Singapore and Turkey by way of the inner route of the Great Barrier Reef and Torres Straits. The vessel had a maximum draft of about 11.0m and required a suitable "tidal window" to navigate the Prince of Wales Channel and Varzin Passage of the Torres Straits.

At Hay Point a licensed pilot joined the ship, to take charge of the navigation for the passage through the Reef.

On the evening of 4 November, the vessel anchored on the eastern side of Prince of Wales Channel, awaiting a sufficient rise in the sea level to safely navigate Varzin Passage on the western side. At about 2330, the vessel weighed anchor and transited the Prince of Wales Channel. When approaching Varzin Passage at about 0200, the broadcasting tide gauge at Booby Island indicated there was insufficient water for the ship to pass safely.

The Pilot decided to delay the ship by turning a wide circle to port. When almost halfway through the turn, the vessel stopped swinging despite port rudder being applied. The ship was travelling slowly and, concerned that the ship might be touching the seabed, the engines were put astern. After 20 to 30 minutes the vessel had gained sufficient stern way to take it into safe water, where the ship was checked for possible damage before passing through Varzin Passage.

Nobody was hurt as a result of the incident; no damage was reported to the ship and no pollution resulted.

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.

1. There is no clear evidence that the vessel actually took the ground, although it is probable that the ship did touch the seabed. Whatever happened, the ship was in water where the depth was such that it was unable to maintain forward movement in safety and there was insufficient under keel clearance.
2. The Master's statement that the ship's deepest draught of 11.0m was accurate within acceptable limits.
3. Atmospheric conditions resulted in the depth of water being less than that predicted and lagging in time.
4. The Pilot's passage plan took into account the need to anchor to the east of the Prince of Wales Channel, however, in view of the actual tidal conditions as broadcast by the "real-time" tide gauges, M Nuri Cerrahoglu left the anchorage north of Alpha Rock prematurely in view of the tidal conditions within the Prince of Wales Channel.
5. The ship's speed made good over the ground between Alert Patches and Harrison Rock buoy was faster than that anticipated from the allowance made for the tidal stream and the ship's propeller revolution setting.
6. There is no evidence that M Nuri Cerrahoglu was closer to Larpent Bank than the position fixed by the Master and Mate.
7. The evidence, provided by the survey conducted by Laser Airborne Depth Sounder, is that the charted depths shown on the chart in the immediate area of the grounding were accurate, within the tolerances published by the Hydrographic Office.
8. The turn to port started at or just after 0200 on 5 November in a position 1.9 miles north of Larpent Bank, was to allow time for the tide to rise in Varzin Passage, it was therefore reasonable to use only ten degrees of rudder and to proceed at a slow speed, providing the ship's turn was monitored to ensure safe passage.

Factual Information

On the morning of the day of the accident, an employee of the property owner accompanied the pilot of the helicopter on an inspection flight of the crops to be sprayed and of the powerlines considered hazardous to the operation. Three areas were to be treated, ranging in size from 5ha to 40ha.

After treatment of the two larger areas was completed, the pilot began spraying a 5ha potato crop. The helicopter was subsequently seen manoeuvring to the west of the crop. Because it had not been seen manoeuvring in this area before, witnesses believed that the pilot was probably positioning the helicopter for a clean-up run. Shortly after, while proceeding in a southerly direction in a level flight attitude, the landing skids struck a powerline suspended across a gully.  The helicopter pitched forward violently, causing the main rotor to sever the tail boom. The aircraft then tumbled to the ground, coming to rest inverted, before a fierce fire broke out.

The pilot was rescued from the burning wreckage and given first aid until medical and rescue personnel arrived. However, he had sustained burns to 90% of his body and died 17 days after the accident.

The powerline was aligned in a north-west/south-east direction. The helicopter had struck a 450m span

approximately 16 m above the ground. During the inspection flight, the pilot had reportedly been made aware of the powerline. Soon after his rescue, the pilot indicated that he was unaware of what the aircraft had struck. Visibility at the time of the accident was good. However, the powerline was extremely difficult to see in the bright sunlight because the pilot's perspective was such that the powerline was below the horizon and tended to merge into the background terrain. The length of the wire span and the location of the supporting poles in relation to the treatment area made it unlikely that the pilot would have been alerted to the existence of the powerline.

Because of his injuries, the pilot was unable to provide further information concerning the circumstances of the accident.

Significant Factors

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

1. It is most probable that the pilot forgot about the location of the powerline.
2. In the prevailing conditions the powerline would have been extremely difficult to see from the helicopter.

Factual Information

The pilot took off from Frogs Hollow Airfield in an amateur-built Skybolt biplane to carry out aerobatic routines. Witnesses advised that the aircraft climbed to approximately 3,000 ft above the airfield and commenced manoeuvres that included stall turns, one and two turn spins, a flick roll and loops. The pilot then carried out one turn through 360 degrees rolling the aircraft about its longitudinal axis during the turn. The pilot then flew an inverted 360-degree turn. After a pause, he climbed vertically, carried out either a stall turn or wingover and entered an 'erect' or upright spin. After one turn of the spin, the aircraft's attitude was seen to change from 'erect' to inverted.

Witnesses advised that as the aircraft descended, the spin may have changed in direction and as it got closer to the ground, the nose began to drop. At about 1,000 ft above ground level the aircraft was observed to be spinning to the right. The rate of rotation began to decrease, with the nose dropping through the vertical.  The aircraft then entered an erect spiral dive from which it was recovering when it impacted the ground and caught fire. The impact was not survivable.

The wreckage and wreckage trail indicated that at impact, the aircraft was approximately 40 degrees nose down, right wing low, rotating to the right, with some forward momentum. This is consistent with witness evidence that indicated that the aircraft was probably in the early stages of recovery from a spiral dive.

The engine noise was reported to be normal until immediately prior to impact when power was removed, re-applied, then removed again. Examination of the wreckage did not disclose any evidence of pre-impact distress with the engine, the airframe or systems.

The weather was fine, with scattered high cloud, and was not considered to be a factor in the accident.

The aircraft was properly certificated, had been properly maintained and serviced and had a valid maintenance release.

The aircraft had been refuelled with sufficient fuel for the flight and was correctly loaded with respect to its centre of gravity. The pilot had carried out a pre-flight inspection of the aircraft during which he had set the altimeter to record height above the airfield, known as QFE.

The pilot's licence and medical certificate were valid.

The pilot commenced flying in 1959 and over the next 35 years had flown 722 hours. He was reported to have been a competent, self-taught aerobatic pilot. There was no record of the pilot receiving formal aerobatic training except for a brief period of instruction in spin recovery when he was endorsed on the Skybolt. The pilot's licence did not have an endorsement permitting him to conduct low-level aerobatic manoeuvres below 3,000 ft.  He had not been a member of the Australian Aerobatic Club.

He had flown 83 flights totalling some 60 hours in the Skybolt in the three years that it had been based at Frogs Hollow. Most of that flying had been in the first year when he flew 47 flights. In the second year he flew 22 flights, and in the year prior to the accident, 14 flights.  He flew most weekends and regularly flew a variety of single-engine aircraft that were based on the field. The majority of his Skybolt flights averaged approximately 30 minutes duration and involved essentially the same aerobatic routine as carried out prior to the accident, with the exception of the inverted spin.

The pilot had been observed to carry out a small number of inverted spins, but these had always been commenced at approximately 6,000 ft above ground level. Witnesses advised that on these occasions the aircraft was seen to generate high rates of descent and rotation and took an estimated 2,000 ft to enter a nose-down spin and subsequently recover to level flight. The pilot had not been observed to attempt an inverted spin from the 3,000 ft height from where he normally commenced his aerobatic routines. The last time he was observed to do an inverted spin was six months prior to the accident.

The Skybolt is described as an easy to fly, docile aircraft. The owner /builder of another Skybolt aircraft advised that he recovered instantly to horizontal flight from an inadvertent inverted spin when he closed the throttle, let go of all controls and then pushed on the anti-spin rudder. The aircraft flicked upright, and he was able to fly out of the manoeuvre.

However, even though they are built to the same plans, there are variations between aircraft. Each is built by a different builder and, being a biplane, is more subject to the effects of rigging tolerances than a conventional aircraft. When it was new, the aircraft was test flown to a more simplified procedure than that used for production aircraft manufactured to Federal Aviation Regulation 23 (FAR23). Therefore, there is little available data in regard to this particular Skybolt's handling characteristics, nor is there any documented comparison of this particular aircraft against others built in Australia.

Prior to the accident flight the pilot flew with a colleague to a neighbouring airstrip. They walked the length of the sloping strip and the pilot was observed to be breathing heavily and appeared to be unfit.  The colleague advised that this was the first time that he had observed the pilot to be other than fit and well.

Subsequent enquires found that the pilot had suffered from mild hypertension, for which he was reported to be taking Diazide or Renetic tablets, and that he was a mild hay fever sufferer. The post-mortem examination found no evidence of possible chest infection, but did disclose fibrous changes throughout the lungs that may have been due to pulmonary fibrosis, the causes of which are unknown.

As a condition of his licence, the pilot was required to wear glasses at all times while flying but was known to wear them selectively. He was not observed to be wearing them for this flight, nor were his glasses located in the wreckage.

Analysis

The pilot may have knowingly placed the aircraft into an inverted spin, or he may have suffered disorientation from 'G' induced loss of consciousness, otherwise known as G-LOC. The investigation was not able to positively determine if either of these scenarios had occurred.

G-LOC may have been induced during the pull up prior to the stall turn or wing over manoeuvre that preceded the inverted spin. If the pull up induced G-LOC, the pilot would have had to remain fully conscious at least to the point where full rudder was applied to induce the stall turn or wing over.  The subsequent changes to the aircraft's state may have occurred due to the pilot being disoriented and confused following a G-LOC episode.

However, the Skybolt aircraft has the reputation of being an easy aircraft to fly and the pilot was known to have successfully flown inverted spins in this aircraft. Witnesses to the flight did not describe the sequence to have been other than normal, except that the inverted spin was commenced at a lower height than before, and the recovery was not successful. Accordingly, it is possible that the pilot knowingly placed and held the aircraft in an inverted spin, intending to recover by allowing the nose to drop through the vertical until the aircraft was in an erect spiral dive, consistent with his previous routines.

The change in power during the final seconds of flight was most probably as a result of the pilot realising that he was too low and that an impact was inevitable. This realisation could have occurred regardless of whether the pilot had deliberately flown into the inverted spin, or due to G-LOC induced confusion.

The pilot may have been unwell on the day.  However, he had continued flying and obviously did not consider his symptoms to be enough to stop him performing the planned aerobatic sequences.

It is conceivable that the perceived lack of fitness may have increased his susceptibility to G-LOC. However, the medications he was taking for mild hypertension and mild asthma are not considered significant.

It is not known why the pilot did not wear his glasses, nor is known what effect the lack of glasses had on the pilot's ability to observe and react to the indications of attitude and altitude that were available to him.

The pilot had flown the Skybolt for only 14 flights, totalling less than 7 hours in the past year. This low level of currency would not be considered sufficient to maintain aerobatic competency, especially in light of the technically and physically demanding routines being attempted.

The pilot had not undertaken any formal instruction in aerobatic flying. Civil Aviation Regulations in force at the time of the accident required that acrobatic manoeuvres be completed 3,000 ft above the terrain. It is not known why the pilot commenced his manoeuvre at a height at which he should have been completing his recovery to level flight.

Conclusions

Findings

1. The aircraft was properly certificated and was serviceable.
2. The pilot held a valid licence and medical certificate, but he was not endorsed to conduct acrobatic manoeuvres below 3,000 ft.
3. Formal instruction in aerobatic flying had not been undertaken by the pilot.
4. The pilot had very low total and recent experience on the Skybolt aircraft.
5. The aircraft entered an inverted spin. The reason why this occurred was not determined.
6. The recovery procedure employed by the pilot did not ensure a rapid recovery to level flight.
7. The aircraft flew into the ground before recovery was effected.

Significant factors

1. The aircraft entered an inverted spin at a low height.
2. The pilot did not apply timely and effective recovery actions.

FACTUAL INFORMATION

History of the flight

The pilot was conducting a private ferry flight from Port Campbell, via Geelong, to Moorabbin airport for maintenance to rectify a tail rotor vibration. Six kilometres south of Moorabbin, while the helicopter was cruising at an estimated indicated airspeed of 70 kts at 700 ft, both lugs of a clevis failed on the left centre frame aft cluster fitting. The failure freed the lower end of the left tail boom support strut. This allowed the tail boom to lift into the main rotor, which cut off the tail boom. The helicopter broke up in flight falling into shallow water 50 m from a beach.

Pilot information

The 38 year old pilot was correctly qualified and endorsed to perform the flight. He held a commercial helicopter pilot licence and a class one medical certificate. However, he was not a licensed aircraft maintenance engineer, nor did he hold a maintenance authority entitling him to certify for 50-hourly inspections on the helicopter.

Meteorological information

At the time of the accident the weather was fine, there was no significant cloud, there was a light wind and no known turbulence. Weather was not a factor in the accident.

In-flight breakup and impact

When the left tail boom support strut detached from the aft cluster fitting, the tail boom swung to the right and lifted, thereby misaligning the tail boom with the internal tail rotor drive shaft. The forward bulkhead of the tail boom severed the drive shaft. The tail boom lifted high enough for the main rotor blades to cut off the aft section of the tail boom along with the tail rotor gearbox, tail rotor assembly and stabilisers. The static mast snapped due to overload and the main rotor assembly, its drive shaft and about half of the static mast detached from the helicopter. The cabin, engine, main gearbox and landing gear assembly remained together until impact with the sea.

Final impact occurred with the back of the cabin facing the sea. The accident was not survivable.

Engine

Rotational damage to the cooling fan and the starter ring gear confirmed that the engine was still running at impact with the sea. No fault was found with the engine which may have contributed to the accident.

Airframe particulars

The pilot was also the owner of the aircraft. He purchased the helicopter on 8 October 1992. Records show that at the time of purchase, the airframe had accrued 4,130 hours total time in service. Since the purchase, the helicopter had been used primarily for short scenic flights averaging about 15 minutes per flight. At the time of the accident the total time in service for the aircraft was 4,333 hours.

Maintenance history

There was no inserviceability recorded in the maintenance release for the helicopter.

A review of the helicopter's maintenance documentation found that the Civil Aviation Authority's Airworthiness Directive AD/HU269/57 Amendment 1, requiring inspection of the aft cluster fittings for cracks, had been certified in the airframe logbooks five times since 16 July 1988. This airworthiness directive inspection was carried out at intervals shorter than the required 200 hours.

The tail boom, a life-limited component, was replaced at the major inspection on 18 October 1993, at 4,149.9 hours total time in service.

The tail rotor was last balanced approximately 200 flight hours prior to the accident, and the last 50-hourly inspection was certified, by the pilot, on 8 January 1995 at 4,293 hours total time in service.

The pilot had certified for daily inspections on a regular basis up to and including the second-last flight, which occurred on 12 February 1995. (The daily inspection for the final flight had not been signed off.)  A pilot's daily inspection, as per the approved Hughes 269C flight manual, requires that the tail boom supports and fittings be visually inspected for cracks, looseness and security. Clevis cracks were not detected during mandatory daily inspections prior to the accident.

Airworthiness Directive AD/HU269/92 required "No Step" placards on the tail boom support struts to warn personnel not to step on them when inspecting the main rotor head assemblies during daily/pre-flight inspections. After the accident, no placards were found on the struts. Notwithstanding the lack of placards, no evidence was found that the support struts were being used as steps.

Aft cluster fitting inspections

Airworthiness Directive AD/HU269/57 Amendment 1 required the inspection of the cluster fittings to be carried out in accordance with Hughes Service Information Notice N-82.3. Note 1 of this airworthiness directive required that improved fittings of -3 designation on all model 269 helicopters be inspected. The compliance was in two steps. Step 1 required a visual examination at each daily inspection and Step 2 required a dye penetrant inspection at intervals not exceeding 200 hours time in service from the last inspection.

However, on page one of the notice, readers were advised that -3 cluster fittings were not subject to the requirements of N-82.3 because these fitting configurations are designed and manufactured with lugs having increased thickness, making them less susceptible to cracks and structural damage.

Also, on page four of N-82.3 (within Step 2), a note stated that the -3 fittings do not require paint removal and dye check, unless cracking, deformation or damage is suspected.

As a result of this ambiguity, at the last 200-hourly inspection, the certifying licensed aircraft maintenance engineer only visually inspected the helicopter's aft cluster fittings. His technique was to clean the area to be inspected with aviation gasoline and then, using a magnifying glass, search for evidence of cracking.  He found no evidence of cracking.

Soon after this accident, the Civil Aviation Authority issued Airworthiness Directive AD/HU269/57 Amendment 2.

This amendment clarified the inspection criteria for cluster fittings on all Australian registered Hughes/Schweizer 269 helicopters.  This directive had to be completed within 5 hours of service after 3 March 1995. No record was found of reports of aft cluster fitting lug cracks in the Australian fleet of Hughes/Schweizer 269s since the issue of this amended airworthiness directive.

Metallurgical examination

Examination of the left side aft cluster fitting upper lug identified that it had failed in fatigue. The fatigue crack initiated from multiple origins adjacent to a small area of mechanical damage on the outer surface of the upper lug webbing radius and propagated across the entire cross section of the lug. The lower lug fitting contained two fatigue fractures growing on different planes as well as an overload fracture.

The observed fatigue striations were evenly spaced, typical of propagation by constant amplitude load, such as vibration load. Striation spacing on the upper lug was smaller than on the lower lug, suggesting that the upper lug fracture initiated first.

On the upper lug fracture surface, 34 faint propagation marks were detected. The marks were distinguishable by thin layers of superficial oxidisation/rust.  The examining metallurgist commented that each progression mark may have represented a flight cycle.

No evidence of localised plastic deformation of the lugs was found, and no historical evidence was found that the fatigue fracture might have initiated from overload due to abuse.

Staining and discolouration of the paint adjacent to the upper lug indicated that the paint was fractured for some time.

The metallurgist found some evidence that the right-side aft cluster fitting had been repainted, but no residue penetrant was detected.

In the opinion of the metallurgist, the upper lug fracture would have been visible for some time during daily inspections.

Vibrations

During the wreckage examination, the tail rotor teeter hinge bearings were found to be worn. The possibility exists that the worn bearings may have caused tail rotor vibrations which may have contributed to the fatigue cracking of the aft cluster fitting.

A part-time pilot who flew the helicopter only 3 days before the accident, was aware of wear in the tail rotor teeter hinge bearings. He stated that a tail rotor vibration was not noticeable in flight through the anti-torque pedals. However, he further stated that a tail rotor vibration could occasionally be felt on the ground with the engine operating at 3,100 revolutions per minute (RPM), the collective fully down and the main rotor spinning at flight RPM. He also stated that occasionally the tail skid could be seen vibrating while the helicopter was ground running prior to take-off. He advised that he discussed the worn bearings with the pilot/owner.

The manufacturer advised that an excessive tail boom vibration situation was one of the conditions the fitting was subjected to during the testing stages of the product.

Examination of other tail boom components revealed no evidence of being affected by tail rotor vibrations.

ANALYSIS

The accident resulted from in-flight fatigue failure of the clevis lugs on the left aft cluster fitting.

Although the duration of the fatigue failure propagation is not known, the fracture probably initiated in the later stages of the helicopter's operational life and propagated within a relatively short period of time. This assumption is based on the following:

1. There was an absence of heavy oxidisation on the fracture surfaces.
2. The faint propagation marks identified on the upper lug surface appeared to have occurred as a result of oxidation of fresh cracking during and after flight.
3. The fatigue striations were uniform. The helicopter underwent substantial maintenance about 200 hours flight time before the accident, when the tail boom was replaced. At about that time, the main and tail rotor assemblies were reassembled and balanced. Changes in striation spacing would have been expected as a result of the maintenance performed. No changes were found.
4. It is considered likely that, had the upper lug been cracked, it would have been discovered by an engineer during the last tail boom replacement.
5. The helicopter flew only 433 hours within the past 6 years. Within that time five Airworthiness Directive AD/HU269/57 Amendment 1 inspections of the aft cluster fittings had been certified by engineers.

It is possible that an unusual load could have been applied to the aft cluster fitting during past helicopter ground handling, or perhaps during an unrecorded heavy landing, or during tail boom replacement or other maintenance. However, during the subsequent metallurgical examination of the fitting, no evidence of localised plastic deformation of the lugs was found, and no historical evidence was found that the fatigue fracture might have initiated from overload due to abuse.

The possibility exists that tail rotor vibration caused by the worn teeter hinge bearing contributed to the accident.

SIGNIFICANT FACTOR

Fatigue cracks progressed undetected in the clevis lugs of the left centre frame aft cluster fitting.

SAFETY ACTION

The Civil Aviation Authority issued Airworthiness Directive AD/HU269/57 Amendment 2, which clarified the requirement to remove paint and inspect the entire cluster fitting using a colour contrast or florescent dye penetrant. Compliance was within 5 hours time in service after 3 March 1995 and thereafter within 200 hours time in service from the last inspection.

The Civil Aviation Authority sent a copy of Airworthiness Directive AD/HU269/57 Amendment 2 to the current aircraft manufacturer, Schweizer Aircraft Corporation.

The manufacturer was also given a copy of Specialist Report 14-95, Metallurgical Examination of Centre Frame Cluster Fittings from Hughes 269C Helicopter.

Summary

On Saturday, 1 October 1994, the Indian bulk carrier Chennai Nermai, while entering the Tasmanian port of Burnie under pilotage and being turned within the harbour, made heavy contact with McGaw Pier. The concrete pier was penetrated to a depth of about 4m and the ship sustained damage to the stem and bow plating.

Conclusions

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

It is considered that the contact with McGaw Pier, brought about by Chennai Nermai not stopping and swinging as the Pilot expected, was primarily the result of three factors:

1. The on-board practice of manoeuvring the vessel at engine speeds lower than the speeds indicated in the vessel's manoeuvring data.
2. The fact that the Master did not give a double ring "full astern" to obtain full astern power when the Pilot first asked for more power.
3. The lack of communication between the Master and the Pilot, in that:
   • The Master did not provide the Pilot with a duly completed pilot card and did not explain the on-board practice of manoeuvring at lower than listed engine speeds, but that "normal" "full astern" could be readily and quickly achieved by a double ring astern.
   • The Pilot did not request a pilot card or seek clarification of the poor astern power and did not discuss the port entry, vessel swing and berthing operations with the Master.

It is further considered that:

1. The drag effect of the tug Spring Cove, towed alongside to port, may have been a contributing factor to Chennai Nermai being slow to turn to starboard and not swinging clear of McGaw Pier.
2. The under-keel clearance of 5.5m in the turning area was sufficient not to adversely affect manoeuvrability.
3. The encroaching darkness was unlikely to have affected the Pilot's judgement.

Summary

At 0840 on 29 September 1994, the Russian container vessel Kapitan Serykh sailed from Brotherson Dock, Botany Bay under the direction of a pilot of the Sydney Ports Pilot Service and with the assistance of two tugs. The wind was from the north-west at 20-30 knots.

The vessel cleared the dock stem first and was then turned to starboard to make the approach to the dredged departure channel. The two tugs were released as soon as the vessel had been turned in the swinging basin.

Kapitan Serykh failed to provide sufficient propeller thrust and to gain sufficient speed to fully execute the eighty degrees turn into the departure channel, despite the Pilot's repeated call for full ahead and grounded on the south side of the channel at 0900.

The vessel was refloated, with the assistance of tugs, after about half an hour and returned to Brotherson Dock, where divers ascertained there had been no structural damage to the vessel.

Conclusions

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

It is considered that:

1. The grounding was the result of Kapitan Serykh not attaining sufficient propeller thrust/speed to execute the turn on to the leads in the wind conditions at the time.
2. The exchange of information between the Master and the Pilot did not conform to the requirements of the International Convention on Standards of Training, Certification and Watch keeping for Seafarers, or with the guidelines contained in the International Chamber of Shipping's "Bridge Procedures Guide".
3. For reasons unknown, the Master did not provide the manoeuvring full ahead pitch, as indicated on the pilot card, repeatedly requested by the Pilot.
4. The option of putting Kapitan Serykh aground on the sand shelf, as against colliding with no.6 beacon, was the one less likely to cause damage to the vessel.
5. Had the Pilot been informed of the steerage problem during port entry in the high winds on 27 September 1994, he would have been forewarned of a possible problem during departure.
6. It would appear to be appropriate, under strong wind conditions, for a pilot aboard a high windage area vessel to retain the tug(s) until the turn on to the Port Botany leads has been seen to be progressing satisfactorily and for the Port and Pilotage authorities to have a written policy on the subject.

Summary

At about 1100 on 9 August 1994, the Panama flag bulk carrier Kayax was alongside in the port of Portland, Victoria, to load a full cargo of grain.

A Surveyor from the Australian Maritime Safety Authority boarded the vessel to undertake a grain loading inspection and a port state control inspection.

As part of the port state control inspection, the port lifeboat was lowered to the boat deck and then recovered to its embarkation position at the davit head. In this position the surveyor asked to see the lifeboat engine run ahead and astern. After some minutes, with the engine running but the shaft in neutral, the boat suddenly became detached from the lifeboat falls and fell to the water, a distance of a little under 20m.

In the boat were the Second Mate and two ratings. The Master was just getting in when the boat fell. The four men were admitted to hospital with significant injuries, the Second Mate suffering serious head and spine injuries requiring prolonged hospital care and rehabilitation.

The boat was recovered from the water and an investigation initiated into the circumstances and causes of the incident.

Conclusions

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

1. The boat was released by the operation of the releasing handle by one of three people actually in the boat.
2. The port lifeboat on-load release mechanism safety pin preventing movement of the quadrant was not in position and the release system was in the "armed" condition.
3. Although the boats were swung out at regular intervals and the general maintenance ensured the boats were in good working order, the vessel's crew were insufficiently practiced in using the on-load release gear.
4. None of the three people in the boat understood how the on-load release mechanism operated.
5. The two languages used in the instruction manual and on notices inside the boats were inappropriate, given the nationalities of those involved, and the instruction diagrams were not fully understandable without a good knowledge of either Japanese or English.
6. Difficulties in communication through the differing nationalities was a factor in understanding the release mechanism and in passing instructions covering non-standard operations.
7. The incident could have been prevented by the fitting of an operational interlock designed to ensure a two-stage release.

Summary

On the night of 28-29 April 1994, the privately owned Provincial Trader became disabled in the eastern area of Bass Strait, whilst on a voyage from Adelaide to Cairns. Provincial Trader was a former tug of 418 gross registered tonnes [739 tonnes displacement] with a length of 42m.

The skipper advised Melbourne Marine Communications Service of the situation and later contacted the owner in Cairns. The owner arranged for the Eden based 14.8m work boat Broadwater to tow the vessel the 100 or so miles to Eden and also to take out some compressed air bottles to the vessel. Broadwater commenced the tow at 0300 on 30 April but proved inadequate and the tow was relinquished to the fishing vessel Rubicon at 1215 on 30 April.

Water had been accumulating in Provincial Trader's engine room bilge from early on 29 April, eventually causing some concern. However, the engineer was able to start the bilge pump after receiving the compressed air bottles and the water level was reduced and stabilised.

When the tow was approaching Twofold Bay, NSW, early on 1 May, Provincial Trader's engine room suddenly and rapidly filled with water and the skipper ordered the crew to abandon ship. Provincial Trader sank just 530m outside the Eden port limits, the crew being rescued by Rubicon.

Conclusions

It is considered that:

1. Provincial Trader foundered as a result of a sudden great increase in water ingress, but it was not possible to ascertain the cause or the point of ingress.
2. The skipper and engineer acted appropriately to the conditions existing at the various times and the loss of Provincial Trader was not the direct result of those actions.
3. Notwithstanding the fact that the vessel was registered with the South Australian Authorities as a motorboat (pleasure craft), there were insufficient proficient crew members on board to undertake the voyage safely and to respond to the emergency.
4. Broadwater was not a suitable vessel for the task.
5. Had a suitable towing vessel been engaged in the initial stages, Provincial Trader would most probably have been delivered timely and safely to Eden before the flooding occurred.
6. Had a salvage pump been delivered by Broadwater or transferred from Osprey, it is a matter of conjecture as to whether the emergency situation would have arisen. With a salvage pump to back up the bilge pump, the increased inflow of water may have been contained until such time as the vessel had been delivered into Eden harbour.
7. Bearing in mind the age of the vessel, the time out of survey and in lay up, a full survey to ensure seaworthiness would have been appropriate before Provincial Trader sailed from Adelaide.
8. Commonwealth and State legislation is deficient in that not all definitions are standard and common to the various jurisdictions.