Collision with terrain

The aircraft departed Gayndah at 0632 hours on a survey flight. This was the first flight of the day. The survey was terminated near a position about four kilometres north of Mt Goonaneman and the aircraft landed at Gayndah at 1138 hours. The crew assisted the oncoming crew to refuel and prepare the aircraft for the next flight. The aircraft was seen departing Gayndah shortly after 1200 hours. At about 1235 hours witnesses saw a column of smoke in the vicinity of Mt Goonaneman and notified Biggenden Police. The accident site was located by the police about 40 minutes later. The survey flights were being conducted at 80 metres above ground level and traversed the survey area on a flight path which was orientated in a north-easterly/south-westerly direction. The tracks being flown were about 40 kilometres long and 200 metres apart. The accident location indicates that the aircraft was on the first survey line adjacent to the position at which the earlier flight had finished, and was travelling in a north- easterly direction towards the mountain when the accident occurred. Witness observations were not conclusive in establishing the final flight path, however, some of the hearing reports were consistent in describing an unusual noise from the aircraft immediately before the accident. The engine noise was heard by one witness to cease and then recommence twice in quick succession. This could have been caused by a serious engine malfunction or changes made to engine controls by the pilot. Another witness reported seeing the aircraft make what he described as a steep climb and a sharp "U" turn near the mountain. This was not a normal manoeuvre for the aircraft to make and this witness may have observed the aircraft during the accident sequence. Unfortunately the time of this observation could not be established in relation to the time of the accident. The examination of the wreckage was hampered by the extensive destruction resulting from the post impact fire. Dust that was found in the fuel injectors from the left engine could have caused an engine malfunction but this could not be positively established. The right engine could not be fully examined due to fire damage. The propellers from both engines indicated that substantial power was being delivered at the time of impact. The nature of the ground impact was indicative of very low forward speed, high vertical speed, in a steep nose down, right wing low attitude. The pilot was very experienced, and it is considered to be most unlikely that he would allow such a situation to develop, or that he would attempt any unusual manoeuvre at low altitude near the mountain. There is no evidence to suggest that aircraft may have failed structurally, or that the pilot would not have been able to cope with any situation, other than that which had the potential to cause a sudden loss of consciousness. Pathology disclosed evidence of a heart condition in the pilot which could have caused sudden death or incapacity. The pilot's last medical examination, conducted in February 1988, had included an ECG. Had the pilot suffered incapacitation, the crewman, seated in the cabin behind the pilot would have had insufficient time, due to the low operating altitude, to correct the situation.

The pilot was engaged in the spraying of sugar cane. During one of the swath runs as he turned the aircraft to follow the line of the cane the right wing struck the cane. The aircraft impacted the ground and bounced several times before coming to rest. The configuration of the spray run chosen, by the pilot, involved a turn through 33 degrees during the run. The aircraft was being operated at a lower altitude than was necessary under the prevailing conditions to complete the task. The combination of both these facts made the judgement of wingtip clearance during the run extremely difficult.

Circumstances:

The aircraft departed Narromine in company with three other gliders for a cross-country flight Narromine - Parkes - Condobolin - Narromine. Weather conditions were fine with good visibility but were otherwise difficult with weak and well-separated thermals being the only sources of lift. North of Parkes all four aircraft had descended to a low altitude. The other three pilots were able to use the weak lift to continue the flight but the pilot of VH-IUB decided that he was unable to continue and informed the other pilots by radio that he would land in a paddock. A south westerly wind of about five knots was blowing on the surface. The aircraft approached the paddock from the south west. In the latter part of the approach, at very low altitude, the pilot initiated a left turn to track away from trees at the edge of the paddock. During the turn the left wingtip struck the ground initiating a cartwheel motion. The fuselage impacted heavily in a steep nose-down attitude. The aircraft was destroyed and the pilot received fatal injuries. The pilot was a qualified glider pilot who had begun gliding ten years previously. However, he had only recently purchased the glider and resumed gliding after a layoff of several years. Stress and fatigue were possible factors in the accident, potential sources being a. the workload required to fly a cross-country route in conditions of poor lift; b. concern about the loss of an important horse sale; c. about sixteen hours driving, including caravan and glider trailer towing, in the 72 hours prior to the accident; and d. pressure to launch on the flight. Before DEPARTURE from Narromine the aircraft altimeters were set to read zero (QFE). Narromine Aerodrome is 782 feet Above Mean Sea Level (AMSL) and Parkes Aerodrome is 1069 feet AMSL. Consequently, an aircraft operating in the Parkes area, with Narromine QFE set on the altimeter subscale, would have approximately 300 feet less terrain clearance than at Narromine. A pilot lacking in currency, under a high workload, and possibly suffering from stress and fatigue, could fail to take this difference into account when considering the minimum altitude required for a safe outlanding. Examination of the wreckage did not reveal any defect that may have contributed to the accident. In March 1988, the wings were reprofiled from the original Wortmann FX67 airfoil sections to modified sections developed from research in USA. There is no evidence to indicate that the wing reprofiling resulted in the need for enhanced pilot skills for safe operation. The pilot was aware of the reprofiled airfoils.

Significant Factors:

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

1. The pilot lacked recent experience.

2. The pilot could have been suffering the effects of stress and fatigue.

3. The pilot misjudged the altitude required and the approach direction during an outlanding.

At the time of the attempted take-off, the night was dark, with overcast cloud conditions and light rain falling. Wind conditions were light and variable. The pilot reported that initial acceleration was normal, and the aircraft became airborne at about 95 knots. A positive rate of climb was established and the landing gear was selected up. The pilot subsequently advised that the speed then decayed to 90 knots. At this time there was nothing unusual in the engine noise and the controls felt normal. Shortly afterwards the propellers struck the ground 116 metres beyond the end of the runway. The aircraft then struck an embankment and passed through a fence before coming to rest 247 metres from the initial ground strike. Although wind conditions were light and variable when the engines were started, shortly after the accident the wind was moderate from the west/south-west. A detailed analysis conducted by the Bureau of Meteorology indicated that while the pilot was preparing for take-off, a cold front with winds in excess of 20 knots had probably passed over the aerodrome. As the pilot had conducted the take-off on runway 08, there was probably a substantial tailwind component. Conditions were also assessed as suitable for the development of microbursts, but the lack of recording instruments in the area prevented confirmation that this type of phenomenon had in fact occurred. The pilot had been deprived of the opportunity to observe changing wind conditions at the aerodrome. The wind direction indicator adjacent to the threshold of runway 08 was not lit, and the illuminated wind direction indicator was not visible from the point where the aircraft was lined up for take-off.

Circumstances:

The pilot had been in the habit of flying about twice per month for a number of years. Each flight was about 30 minutes long and usually involved aerobatic flying. On this occasion the aircraft was observed conducting loops and a barrel roll in the normal area above 3000 feet above sea level. The aircraft later joined the circuit for a landing. While on the crosswind leg, the aircraft continued to descend until, at about 700 feet above ground level, the aircraft entered a gentle left turn. The nose dropped during the turn until the aircraft was descending at an angle of about 45`. When the aircraft was about 100 feet above the river the angle increased to about 85` nose down. No changes in engine power were heard during this time. The aircraft struck the Clarence River about 40 metres from the shore at an estimated speed of 180 knots. No evidence of pre-existing defects in the control circuits was found, however, the wings had been torn off on impact and large sections of the control circuits were not recovered. Witnesses reported that nothing was observed to fall off the aircraft and no part of the aircraft was flapping during the descent. Pathological examination concluded that the pilot had died as a result of myocardial ischemia (lack of blood supply to the heart). The pilot had been hospitalised some years earlier due to a heart attack. This had not been reported to the medical examiner during subsequent licence medical examinations. Hence, as the required tests had not been conducted during licence renewal, it was not possible to determine whether the pilot may have been able to hold a licence at the time of the accident.

Significant Factors:

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

1. Pilot did not report his medical history accurately.

2. Pilot suffered from coronary artery disease.

3. Pilot died during flight.

The pilot flew to a private airstrip for a visit with fellow aviators. After about one and a half hours he decided to fly home. The aircraft took off to the north and climbed straight ahead to about 100 feet above the ground before making a steep, 180 degree, left turn and descending towards witnesses standing in front of a hangar. About 100 metres south of the witnesses the pilot commenced a left barrel roll from an estimated altitude 60 feet and an airspeed of about 85 knots. The aircraft managed to get over the top of the barrel roll but then descended rapidly. It impacted the ground in a south westerly direction with a nose-low, wings level attitude. It bounced off the ground and came to rest in about 10 metres with the engine dislodged from the airframe and the landing gear collapsed. It has been determined that the aircraft was serviceable prior to the accident. Neither the weather conditions nor the pilot's medical status contributed to the accident. Subsequent inflight checks in a Chipmunk aircraft have confirmed that a complete barrel roll cannot be achieved from an altitude of 60 feet with an entry airspeed of 85 knots. The pilot had been instructed and found competent to carry out barrel rolls at higher altitudes in his Chipmunk in 1966. He gave no prior warning that he was going to attempt to carry out a low level barrel roll.

The Beechcraft Queen Air and Rockwell Aero Commander were being used by a company to conduct private category passenger-carrying flights to transport its workers from Leonora to Laverton in Western Australia. The Aero Commander had departed and was established in the Leonora circuit area when the Queen Air took off. The pilot and one of the passengers of the Queen Air reported the take-off roll appeared normal until the aircraft crossed the runway intersection, when they felt a bump in the aircraft. The pilot reported hearing a loud bang and noticed that the inboard cowl of the right engine had opened. He also reported that he believed he had insufficient runway remaining to stop safely, so he continued the take-off. The cowl separated from the aircraft at the time, or just after the pilot rotated the aircraft to the take-off attitude. He reported that although the aircraft had left the ground after the rotation, it then would not climb. The aircraft remained at almost treetop level until the pilot and front-seat passenger noticed the side of a tailings dump immediately in front of the aircraft. The pilot said that he pulled the control column fully back. The aircraft hit the hillside parallel to the slope of the embankment, with little forward speed. The impact destroyed the aircraft. Although the occupants sustained serious injuries, they evacuated the aircraft without external assistance. There was no post-impact fire. The aircraft-mounted emergency locator transmitter (ELT) did not activate.

The Aero Commander pilot reported the accident to Perth Flight Service at 1746. Flight Service advised the local police of the accident at about 1750, however, the police were unable to locate the occupants until about 1848 because the details of the aircraft's whereabouts provided by the Aero-commander pilot were inaccurate.

Sequence of events

Three days before the accident flight, the Queen Air was privately hired from its owner and used to transport ten workers from Manjimup to Leonora. During the return flight to Manjimup, the pilot discovered that the left engine had developed a fuel leak and the right engine's oil pressure indication was low. The pilot returned the aircraft to Leonora and landed without further incident. He then returned to Manjimup using a commercial air service.

On the day of the accident, the original Queen Air pilot (pilot A) returned to Leonora in the Aero Commander. He was accompanied by a Licensed Aircraft Maintenance Engineer (LAME), another passenger and another pilot (pilot B). Pilot B was to fly the Queen Air to Manjimup.

By about 1330, the LAME had repaired the left engine. Pilot A then conducted a test flight and after landing, the aircraft was shutdown and checked. He then conducted a .6 hour refamiliarisation flight with pilot B. Both pilots reported that the flight included upper air work and three circuits. The aircraft landed at about 1600.

After the refamiliarisation flight, the aircraft was again shutdown and further maintenance was conducted on the left engine. The LAME reported that while he conducted maintenance on the left engine, both pilots were standing next to the right engine with the inboard cowl of the engine open. He reported that the pilots had found a set of pliers in the engine bay. Once he had ascertained that the pliers were not his, the LAME said that he went back to work on the left engine. He reported that he did not do any subsequent maintenance on the right engine and therefore did not check the security of the cowl of the right engine before the aircraft flew again. Pilot B said that he was assisting the LAME at the left engine and that pilot A had found the pliers in the right engine bay. A witness reported that pilot A had opened the right engine cowl and retrieved the pliers however, pilot A reported that pilot B had unfastened the cowls on the right engine to check for a small oil leak.

The pilots' original intentions were that once the Queen Air was repaired, the two aircraft would return the passengers to Manjimup. However, after the test and refamiliarisation flying had been completed, and during the planning for the flight to Manjimup, the pilots decided that the weather at Manjimup was unsuitable for VFR flight. They decided to conduct the flight the following day. Consequently, the pilots, LAME and passengers went to Leonora Township to find accommodation for the night and at about 1700 they met in a local hotel. Because there was insufficient accommodation available in Leonora, the group decided to fly to Kalgoorlie that afternoon. The pilots then became concerned about the wet weather approaching Kalgoorlie and Leonora, so they decided to fly both aircraft and all the passengers to Laverton for the night. Laverton was located about 15 to 20 minutes flying time north of Leonora.

Pilot A, who was flying the Aero Commander, reported that he had conducted the take-off in daylight conditions at about 1710. Pilot B, flying the Queen Air, reported that he had started the engines at the same time as pilot A had started the Aero Commander's engines but the time was about 1720. He reported that he had conducted the take-off in daylight conditions soon after. Documentary evidence indicated that the Aero Commander had been refuelled at about 1726. A witness reported that when he was leaving the airfield, he saw the passengers about a kilometre from the airfield and walking towards it at about 1710. Another witness reported seeing the passengers still walking towards the airfield at 1720 and that the aircraft were both on the tarmac without the engines running. One of the passengers of the Queen Air recalled seeing the Aero Commander depart at about 1730.

One of the passengers in the Aero Commander reported that it was getting dark with the sun just above the horizon when he embarked in the aircraft while pilot A conducted post- refuel checks. He also reported that the Aero Commander taxied about 10 minutes after refuelling and that the Queen Air had not started at the time they taxied. One of the witnesses also reported hearing the aircraft start at about 1735 and seeing one of the aircraft take-off soon after and circle the airfield. He also reported hearing the police sirens at about 1755. The police running sheet shows the police responded to the accident at 1755.

Pilot B reported that he had conducted the run-up checks on the apron before taxying to the runway and backtracking to the threshold of Runway 30. He reported that during the take-off roll he felt a "substantial impact" when the aircraft crossed the runway intersection. The passenger occupying the front passenger seat reported feeling a "fair bump" as the aircraft crossed the intersection. Pilot B said that it was after the bump that he heard a, "loud metallic bang". He reported that the noise caused him to look across the cockpit and out the right side window. He noticed the inboard cowl of the right engine opening in the propeller slipstream. The front seat passenger recalled seeing the cowl open when the aircraft experienced the bump. He said that the cowl fully opened as the aircraft left the ground and soon after, fell away. Another passenger recalled seeing the cowl open and come off before the aircraft took off.

Pilot B recalled having set a power of 45 inches of manifold air pressure (maximum continuous power) on the engines. He also recalled rotating the aircraft to lift off at 85 kts when he saw the engine cowl fall away. He said that he maintained the power setting because he, "was being very careful to avoid an overboost (engine) condition" and that the aircraft would not climb, remaining just above treetop level. He then saw the tailings dump embankment. He said that at about that time, the front seat passenger was telling him to pull up. He pulled back on the control column and the aircraft pancaked onto the embankment.

A passenger located in the Aero Commander, reported seeing the Queen Air "wallowing at low speed" just after it took off. He said that he saw the aircraft's landing lights illuminate the tailing dump before the aircraft pitched-up and bank to the right before hitting the hill. Pilot A reported the accident to Perth Flight Service but the details initially passed indicated that the aircraft had hit the ground on the airfield. The tailings dump was about 1 km beyond the airfield boundary.

Weather information

Last light for Leonora on the day of the accident was at 1732. There was mid- to high-level cloud with the lowest base being about 16,000 ft over the Leonora area. The wind was a light north-westerly.

Airfield information

Runway 12/30 was the only useable runway at Leonora airfield at the time of the accident because extensive works were being conducted on the main runway. Runway 12/30 was not lit and was therefore, unsuitable for use at night.

Pilot Information

Pilot B had extensive experience flying single engine aircraft but had last flown a twin-engine aircraft at night 3 years prior to the refamiliarisation flight. He had not flown a Queen Air for 7 years. He had advised the owner of the Queen Air that he had 300 hours flying experience in the Queen Air aircraft type. However, his pilot's logbook revealed that he had accumulated a total of just 30 hours flying experience in the type of which about 6 hours were as pilot in command. He subsequently reported that he had gained many more, "unofficial", hours in the Queen Air.

His licence was not endorsed with a night visual flight rules (NVFR) rating and his single engine instrument rating had expired 10 months prior to the day of the accident. His multi-engine command instrument rating had expired 6 years previously. The pilot's interpretation of the regulations and orders was such that he claimed that he did not require a NVFR rating because he previously held an instrument rating. The Civil Aviation Safety Authority reported that the pilot's interpretation of the requirements was incorrect.

The pilot who conducted the refamiliarisation flying reported that the accident pilot handled the aircraft well during the short refamiliarisation flight.

Wreckage Examination

The aircraft hit halfway up the embankment of a tailing dump about 1.7 kms from the runway and slightly left of the extended centreline. The embankment was about 30 ft high, with a 38-degree slope. The trees between the runway and the embankment were about 3 to 5 m tall. The fuselage had failed at the rear window line and twisted to the left. The cabin door was torn off and the right cabin windows were broken. The rear left seat had separated from the seat rails and the forward cabin ceiling lining had collapsed onto the seats. A small aluminium ladder was on the rear right seat. Several small hand tools and three protective helmets were in the rear of the cabin. All the cargo was unrestrained although a cargo tie-down net lay loosely in the rear of the cabin. The remote ELT control switch was in the armed position but the ELT had not activated. The ELT was undamaged and mounted correctly behind the rear cabin bulkhead. A subsequent inspection of the ELT found no fault with the unit.

The inboard cowling of the right engine was missing from the wreckage. It was found resting to the right side of the runway, about 850 m from the threshold of runway 30. An engineering inspection of the engine bay and cowl found that all its latches and locking mechanisms were serviceable. The two top hinges had failed in overload. The cowl was otherwise in good condition.

The left propeller and reduction gearbox, both main gears and the lower nose gear had all separated during the accident. Damage to the blades of both propellers was consistent with both engines delivering power at impact. A considerable quantity of Avgas was drained from both wing tanks during the recovery operation. Evidence indicated that both engines were capable of normal operation at the time of the accident.

The aircraft was not fitted, nor was it required to be, with a flight data or voice recorder.

The aircraft's maintenance release had not been completed during the 8 days prior to the accident including the maintenance conducted on the day.

On 20 December 2010, the owner/pilot of a Pacific Aerospace Corporation FU-24-954 Fletcher aircraft, registered VH-FNM, was conducting aerial spreading of urea fertilizer at Wynella Station; a property 40 km south-south-west of Dirranbandi, Queensland. At about 1650 Eastern Standard Time, the pilot was returning to the landing strip after the completion of an application run. The aircraft impacted the terrain, and the pilot was fatally injured.

Examination of the accident site indicated that the aircraft's engine was delivering power at the time of impact. Wreckage examination did not reveal evidence of any defect or mechanical failure that would have contributed to the event. Although the post-mortem report on the pilot noted that he had significant coronary atherosclerosis, there was insufficient information available to determine whether pilot incapacitation was involved in the accident.

The investigation did not identify any organisational or systemic issues that might adversely affect the future safety of aviation operations.