Collision with terrain

The pilot had flown from Adelaide to Bacchus Marsh, on 25 July 1980, and had left the aircraft there while he attended to private matters. On his return during the afternoon of 1 August he discovered that there was no fuel available, and elected to fly to Essendon to refuel and to obtain a pre-flight briefing. It had been the pilot's intention to proceed as far as Horsham and remain overnight before continuing, however the weather forecast was satisfactory and he decided to plan a Night VMC flight to Adelaide. The pilot noted on the plan that the lowest safe altitude on the initial leg to Yarrowee was 3500 feet above mean sea level (amsl), and was 4800 feet amsl between Yarrowee and Mt William. Planned cruising altitudes were below 4000 feet amsl to Yarrowee, thence below 5000 feet amsl. About 25 minutes after DEPARTURE the pilot was advised that the weather at Adelaide was deteriorating and he elected to divert and land at Horsham. Amended flight details were passed, indicating that the aircraft would proceed to Horsham from over Mt William, cruising below 5000 feet amsl. At 2049 Melbourne Flight Service contacted the pilot and requested an estimated time of arrival for the Mt William position. The pilot replied that his revised time for the position was 2051. This was the last transmission received from the aircraft. At about 2050 witnesses noted an intense fire near the summit of Mt William. The following day it was established that the aircraft had collided with the almost vertical face of the mountain, some 400 feet below the summit, while apparently in cruising flight at about 3400 feet amsl and on the track from Yarrowee. The wreckage had then fallen about 200 feet to sloping ground and had been consumed by an intense post-impact fire. The weather at the time of the accident was reported as fine, with good visibility. Although the winds were stronger than forecast, it was considered that there was no significant turbulence or downdrafts in the area. The examination of the wreckage was hampered by the extent of the damage, however no evidence was found to indicate any pre-impact defect which might have contributed to the development of the accident. The reason the pilot was flying the aircraft more than 1000 feet below the lowest safe altitude for the route sector could not be determined.

Circumstances:

The aircraft was departing from an 1100 metre grass strip which contained some soft patches. The pilot reported that the aircraft became airborne after a take-off roll of approximately three quarters of the strip length. He deliberately adopted a shallow climb angle to build up speed. Shortly after crossing the upwind end of the strip, the pilot felt the aircraft sink. The left main landing gear contacted the ground and was torn from its mount. The aircraft came to rest about 200 metres beyond the end of the strip. The pilot was familiar with the strip, but this was his first flight into the strip in a PA-32 aircraft. Previous operations had been in an aircraft of significantly higher performance. Although the pilot had 73 flying hours on type, his only PA-32 experience in the previous seven years was two- and one-half hours in the 24 hours before the accident.

The aircraft was observed to depart Bankstown without a clearance or contact with Bankstown Tower. It was reported that the aircraft was being flown erratically. An uncertainty phase was declared and the progress of the aircraft monitored by radar until contact was lost in the Bringelly area at about 0635 hours. At about that time the aircraft was observed to descend steeply, before striking trees at high speed. It then commenced disintegrating before impacting the ground with great force and came to rest, on fire, in a small dam. The bodies of both occupants were found some distance from the main wreckage.

At about 0200 hours, the owner and a passenger boarded the aircraft for a local flight. A resident heard it take off and saw the aircraft lights in the circuit area. He also noted that the runway lights were illuminated. A go-around was made on the first approach and the aircraft was landed after another circuit. A take off was carried out in the opposite direction and shortly after becoming airborne the aircraft struck the ground. Fire broke out and engulfed the wreckage. It was not possible to determine which of the occupants were manipulating the controls at the time of the accident. Neither person was qualified to operate the aircraft. Post mortem examinations revealed that both persons had high blood alcohol levels.

An inter-club fly-in had been organised at the private airstrip. The club secretary who had organised the meeting had expressed an interest in aerobatics, and arranged to accompany the pilot on a demonstration flight. A series of aerobatic manoeuvres, judged by the witnesses to be of a relatively poor standard, were completed between about 1500 and 3000 feet above ground level. The aircraft was then observed to overfly the aerodrome at about 300 feet agl and enter what appeared to be a roll. When the aircraft reached the inverted attitude, its nose was well below the horizon and the roll was not continued. The nose then lowered further as a "pull-through" manoeuvre was apparently attempted, however the aircraft impacted the ground at high speed before level flight could be regained. Subsequent investigation indicated that the aircraft and its control systems had been serviceable prior to impact with the ground. The pilot was neither approved nor sufficiently experienced to perform aerobatics at a low level and it is probable that on this occasion his actions were influenced by the presence of the group assembled on the ground.

The pilot had been authorised to carry out circuit and landing practice. He had been operating for about 20 minutes when witnesses observed that immediately after lift-off from a touch and go landing, the aircraft assumed a higher than normal nose attitude. At an height of between 100 and 150 feet above the runway, the engine noise ceased and the aircraft pitched forward to a steep nose down attitude. This attitude was maintained until the aircraft impacted the ground, before coming to rest 50 metres to the right of the runway centreline. A subsequent investigation determined that the pilot had probably suffered a heart attack at about the point of lift-off, resulting in incapacitation and loss of aircraft control.

Circumstances:

The aircraft was operating a scheduled service from Brisbane to Port Macquarie with planned intermediate stops at Coolangatta and Coffs Harbour. Weather conditions over the route were influenced by a widespread unstable airmass. The terminal forecast for Coffs Harbour indicated a surface wind of 360/15, visibility in excess of 10 km, 5 octas stratus at 1000 ft, 5 octas cumulus at 2000 ft. Thunderstorms, associated with visibility reduced to 2000 metres were also forecast for periods of up to 30 minutes. The actual weather conditions at Coffs Harbour were generally consistent with the terminal forecast. Runway 03 was in use throughout the evening. Coffs Harbour airport was equipped with NDB, VOR and domestic DME radio navigation aids. A VOR/DME procedure was published for runway 03 approaches. For aircraft not equipped with DME, a VOR or NDB approach was available using common tracking and minimum altitude criteria. Runway 03 was also equipped with a 6 stage T-VASIS and 3 stage runway lighting. All facilities were reported as functioning normally, with the exception of the VOR which was experiencing intermittent power failures due to the effects of heavy rain. The VOR was able to be reset manually from the Coffs Harbour control tower. Although the tower was scheduled to be unmanned before the arrival of VH HOX, the duty air traffic controller elected to man the tower until the aircraft had landed. The controller also called out a technician to attend to the VOR. The aircraft was equipped with dual ILS/VOR and ADF receivers, plus International DME. Domestic DME equipment was not fitted to the aircraft, although required by ANO 20.8. After descending in the VOR/NDB holding pattern, the aircraft was cleared for an instrument approach. The pilot had been told of the intermittent operation of the VOR and had said he would revert to the NDB. At that time, the weather conditions were fluctuating about the circling minima of 950 feet (QNH) and five km visibility. The controller advised the aircraft of a heavy shower to the south of the field. The aircraft subsequently completed the approach and the pilot reported "visual". The controller said he saw the lights of the aircraft in a position consistent with a right downwind leg for a landing on runway 03. The aircraft was then cleared to land. Shortly after, the controller saw the lights of the aircraft disappear briefly, consistent with the aircraft passing through a localised area of rain/cloud. The lights then reappeared briefly, as though the aircraft was turning onto finals, before disappearing. This was immediately followed by short series of "clicks" on the tower frequency. The aircraft was called immediately but failed to respond to any calls. The accident site was located about 1070 metres short of the landing threshold, and about 750 metres to the right of the extended runway centreline. The aircraft was found to have initially struck a nine metre high tree in a nose low attitude, steeply banked to the right, on a track of 050 degrees. After striking the tree with the outboard section of the right wing, the aircraft struck other trees before hitting the ground and overturning. A fire broke out shortly after the aircraft came to rest. As a result of his remaining on duty, the controller was able to provide immediate notification of the accident to the emergency services. This action facilitated the rescue of survivors. A subsequent examination of the aircraft structure, systems and components, found no evidence of any pre-existing defect or malfunction which could have contributed to the accident. The pilot was properly licenced and qualified to conduct the flight. Evidence was provided to show that the pilot had probably flown a total of 930 hours in the previous 365 days, thereby exceeding the ANO 48 limitation of 900 hours. Other breaches of Flight and Duty Limitations were found to have occurred during the previous 12 months, however, during the three months prior to the accident no significant breaches of ANO 48 were found which could have contributed to the accident. Specialist medical advice considered the 30-hour exceedance of the 900-hour limitation was not significant in this accident. Other specialist advice was obtained concerning the possibility of the aircraft being affected by low level windshear or a microburst during the final stage of the night circling approach. It was considered this was not a factor in the accident. Considerable evidence was presented during a subsequent Coroners' Inquest concerning allegations of irregular operating practices by the operator over a period of several years prior to the accident. Much of this evidence was only provided after the granting to witnesses of immunity from prosecution. Despite this, no new evidence was presented which related to the accident flight. The investigation concluded that, on the evidence available, the aircraft was turning onto a short right base leg when it entered a localised area of rain and low cloud. The pilot was required to look out of the right cockpit window to enable him to maintain visual reference with the approach end of the runway. It is considered probable that the pilot briefly diverted his attention from the flight instruments while attempting to maintain that visual reference as the aircraft passed through an area of reduced visibility. During that period, the aircraft continued to roll to the right, resulting in an inadvertent loss of height. The pilot was unable to effect a recovery before the aircraft struck trees.

Significant Factors:

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

1. Low cloud base, with localised rain squalls and reduced visibility.

2. Low level, right hand, night circling approach.

3. Pilot lost visual reference at a critical stage of the approach.

4. Pilot did not initiate missed approach.

5. Pilot probably diverted attention from the flight instruments.

Recommendations:

1. During the course of the investigation it was recommended that the Civil Aviation Authority review its policies and procedures concerning the surveillance of commercial flying operations in general aviation. The objective of the review would be to facilitate the identification and rectification of improper operating practices within the industry. The Authority subsequently advised that the level or frequency of surveillance of commercial aviation operations was being increased.

The aircraft arrived at the destination strip about 40 minutes after last light. Weather conditions in the area were good, with light winds and clear skies, however the night was very dark and there was no visible horizon. Witnesses on the ground reported that the aircraft seemed to be at a normal height on the crosswind leg and as it turned onto downwind. However, it was then seen to enter a gradual but steady descent. About half way along the downwind leg, the lights of the aircraft were lost to sight. The aircraft impacted the ground in a straight and level attitude, bounced 118 metres, and then bounced and skidded for a further 216 metres before coming to rest. No fault was subsequently found with the aircraft which might have contributed to the development of the accident. The pilot lacked recent experience in night operations. He had made only two night flights in the previous 32 months, the most recent being some 11 months prior to the accident. On the downwind leg of the circuit, the pilot had apparently not increased engine power after the gear was lowered. He had also been concentrating on his position relative to the flare path, and had evidently paid insufficient attention to the height of the aircraft.

The pilot was participating in a "ridge soaring camp". After becoming airborne the glider was flown at low level in a south-westerly direction along the ridge line, about 200 feet above the ridge. The pilot then turned the aircraft left towards the ridge in an attempt to gain lift. No lift was gained and the aircraft descended. The pilot then raised the nose of the aircraft to clear the ridge but the right wing struck a tree. The aircraft slewed to the right and descended down the ridge line before impacting the ground. The pilot had intended to turn back towards the ridge but delayed this turn to allow her passenger to take a photograph. The resultant flight path took the aircraft into an area of sink on the leeward side of the ridge. The pilot usually flew the glider from the front cockpit but due to centre of gravity considerations she had to use the rear cockpit which somewhat restricted her forward vision. The volume of the variometer, which was fitted in the front cockpit, was turned down so as not to disturb the passenger, however this action also deprived the pilot of immediate indication of changes in lift. This accident was not the subject of an on-site investigation.

The pilot received a weather briefing before departing Townsville which indicated that the weather enroute was unsuitable for flight under the Visual Flight Rules. After being issued with a clearance to enter Cairns control zone no further transmissions were received from the aircraft and it failed to arrive at Cairns. The wreckage of the aircraft was located in rain forest on the lower southern slopes of the south peak of the Bellenden Ker Range. The weather in the area at the time was reported as low cloud with heavy rain. The pilot was not qualified for flight in other than visual meteorological conditions. Investigation revealed that the aircraft was serviceable prior to impact. Witnesses reported that they observed the aircraft passing in and out of the cloud base, which was at about 800 feet. They saw the aircraft tracking in a northwesterly direction towards high ground which rose to 4000 feet amsl. The wreckage was discovered at an elevation of 680 feet amsl. The pilot was known to have urgent business commitments and this may have influenced his decision to continue the flight in unsuitable weather conditions.