G.\.C ~.

, ...... Commonwealth of Australia

I AVIATION SAFETY DIGEST

...... •

J

No. 12 DECEMBER, 1957

Printed by Hedges & Bell Ply. Ltd , Moryborough, Vic.

. . Aviation Safety News and Views Digest

No. 12 - December, 1957 Flight Instruments and Electrical Power

CONTENTS Failure Warning Page ( Reproduced from Pilots' Safety Exchange Bulletin 57-104 issued by the News and Views Flight Sa/et'' Foundation, N ew York, U.S.A.)

Flight Instruments · and Electrical A recent investigation of an air Power Failure Warning C.A.A. aviation safety agent, a transport accident involving a "sud­ C.A.B. electrical systems specialist Collisions with Overhead W ires 4 and three airline captains. A Lesson Learnt . 6 den and surprising" crash landing almost immediately after take-off, Following are the facts of their disclosed inadequacies in the present­ report - Overseas Accidents day electrical power failure warn­ Crash following Missed Approach - ing system. particularly as it affects At Lhe beginning of the tests, the Douglas DC.6B - Cold Bay, Alaska 7 flight instnunents. While actual in­ aircraft was parked with engines off Mortin 404 Strikes Mountain - ftight instrument failures are not and d.c. power supplied by a ground Albuquerque, New Mexico . . B commonplace, they have happened power unit. The d.c. bus voltage I LS Approach Accident al Blockbushe 10 and have been attested to by highly was measured to be 28 volts. Mag- Martin 404 - Los Vegas, Nevada 1 2 qualified and experienced pilots. 11etic compass heading read 170°. Dove Accident - New Forest Hamp· For example, while on an ILS Captain's and first officer's Collins shire, England 14 approach. the captain of a twin­ Course Indic::itor compass cards DC.4 En-route Collision with Terrain 15 enginc transport reported his horizon read 175°. slowly indicated a bank. The first Main inverters were turned on. Australian Accidents officer, who was flying the plane Captain's selector switch was placed from the left seat, tried to keep the in 'Up' position; engine instnunent DC.4 Damaged in Undershoot 17 airplane in relation to what the selector switch was in 'Up'; first Procrastinotian in a DH.B2 1 8 horizon was telling him. The horizon officer's selector switch was in Agricultural DH.82 Strikes Fence dur- on the right side, however, was in­ ·Down' position. Output voltage of ing Take-off . 1 9 dicating just the reverse, so the cap­ each inverter was measured to be tain corrected the manoeuvre. In­ That Check for Water Needs Careful 115 volts a.c.: freq1wncy 410 c.p.s. Thought 19 vcstiga tion subsequently disclosed Agricultural DH.B2 Collides with that the horizon on the left side had Electricity Wires 21 failed with no warning light indica­ Compass Card Reaction Fatal Accident in Authorized Low tion. The trouble was found to be As inverters were turned on, com­ Flying . 22 in the Phase C circuit - the l 15V pass cards of the' two Collins CouJ"se Agricultural DH.82 Collides with High Phase Circuit breaker had popped Tension Power Cables 22 rndicators were watched closely. out. This incident proves a point Neither changed position. Slaving that may not be well known to any knob of captain's C-2 gyrosyn was one except electronics specialists. Incidents rotaled lo displace the dial. Cap­ namely, that the inverter failure tain's course indicator compass carci It Would Have Been Much Closer warning lights may not give warning slaved to C-2. while first officer's in Cloud 24 where there is loss of only one co11rse indicator card was 11naffected. A Lively Spork 25 phase of AC power. Rudder Control Cable Failure 26 After turning on inve1·ters, time Too Close 26 Jn the light (or lack of it) of this for gyro horizons to erect were: 111ost recent experience, the results captain's horizon - 8 seconds; fi rsl Design Notes of electrical tests performed on a officer's hori7on - 3 minutes. sister-ship of the one involved in Stabilizer Actuator 28 the crash landing may be of interest, Phase A-Upper Inverter particularly 10 those who operate aircraft employing only electrical After allowing the gyros time to (Prepared by Division of Accident Investiga­ fl ight instruments. reach operating speed. Phase A cir­ tion and Anaysis. Published by authority of cuit breaker of 11ppC'r inverter was Director-General.) Those doing the tests included a opened:

1· the Sf'<:ondary voltage was 22.9 volts. and aircraft was taxied to new I. Captain's inverter warning light cuiL breaker ·of lower inverter was Captain's Instrument Transformer reach operating speed, the Phase A did not light. opened: T he gyro horizon had not yet tum­ location for further tests. As air­ circuit breaker of the upper inverter Fuse in Phase A of primary of the bled. craft heading changed, compass was opened. Forty seconds later the 2. Captain's gyro horizon tumbled 1. First officer's inverter warning captain's instrument transfo rmer was A check was made to determine card of first officer's course in­ aircraft was taxied straight ahead. 2 minutes later. Bar moved up light did not come on. removed. T he captain's inverter what effect the C-2 g}'rosyn would dicator rotated and indicated new The gyro tumbled l minute, 10 sec­ and to the left, then over to the warning light did not come on a l li avc on the secondary voltage when headings in agreement with cap­ onds after the circuit breake1· was right. C-2 gyrosyn slaving knob 2. First officer's gyro horizon tum­ once. However, it did come on 5 Phase A circuit breaker was opened. tain's course indicator compass card. opened. The horizon bar' Li lted to was turned and captain's course bled 2 minutes la ter. The hori­ minutes later while the group waited Fuses to the C-2 were removed and On same inverter switch selection, the left. The captain's inverter warn­ indicator compass card followed zon bar lowered with slight til t fo r .t,'yro horizon to tumble. rhc test repeated wherein Phase A Phase A circuit breaker of upper ing light did not come on. The cir­ gyrosyn card. to left, then raised with slight circuit breaker was opened. No dif­ inverter was opened. Engine instru­ cuit breaker was then closed. The Phase A fuse was replaced after tilt to right. I t reached top and ference in seconda ry voltage was ment operation remained normal testing was concluded at this point. 3. Cabin pressure control could not allowing gyros to reach operating rested in level attitude. When noted. The voltage increased from 26 and captain's inverter warning fail­ be checked while unpressurised. speed ; P hase C fuse of primary side Until answers are found to the instrument was tapped by hand, volts to 29 and remained there. ure light remained off. Fuel quanti­ of same transformer was pulled. question of reliable performance of 4. F uel quantity: no reading. bar fell off to left. \'\lith same inverter selection, ty indication ceased. A hard right Captain's inverter warning light electrical flight instruments, ade­ Phase A and Phase B circuit breakers Lurn of 360° was made and only a 5. Engine Analyser: not installed. '.l. Pedestal lights stayed on. came on immediately. quate warning of power or in­ of upper inverter were individually one-half needle width turn was indi­ strwnent failure, etc., it would 6. Zero Reader: Vertical main 4. Power to A-12 gyro pilot was off. Fuse was replaced. Following a opened. Check was made Lo sec if cated by the captain's turn and appear that an alternate means of pointer of the indicator and With aircraft a t rest, slaving of similar procedure, Phase A and C:-2 would slave to flu x \'alves : with bank indicator. T he gyro horizon flight instrumentation is desirable. heading arrow of heading selec­ co-pilot's course indicator card Phase C fuses of secondary side of either circuit breaker open, there was tumbled after 1 m inute and 45 sec­ For example, an air-driven flight tor slaved with C-2. When lo A-12 gyrosyn compass could transformer were individually re­ no slaving action. Slaving of verti­ onds with the horizon bar falling group or non-electrically operated heading selector setting was not be checked. moved. In each case the warning cal main pointer of Zero Reader in­ and tilting to the left. At this time gyro instruments for primary use changed, vertical main pointer ligh l came on as soon as fuse was dica tor was checked. When Phase A it was noted that the C-2 operated rather than utilizing only electricaJ'fy responded. 5. Radio Altimeter: nut installed. removed. circuit breaker was opened, it slaved only as a directional gyro. It was driven instruments. lo C-2 gyrosyn. When Phase C cir­ not slaving to its flux valves. 7. VOR No. 1: went off. 6. Loran: not installed. All instruments were then operated cuit breaker was opened, it did not from the upper inverter and its cir­ The Phase A circuit breaker of the Comment 8. VHF No. 1: went off. 7. ADF No. 2 : R eceiver was off ~l ave . Phase A and P hase C fuses of cuit breakers individually opened to first offi cer's instrument transformer upper inverter was closed. T he Phase and indicator was inoperative. A and Phase C fuses of the Zero Most power failure warning sys­ 9. Glicleslope No. 1 : went off. observe the beha,-iour of the inverter ~econdary were individually removed tems sense a loss of power at the 8. Glideslope Receiver No. 2: This warning lights. \l\lhen Phase A cir­ to see effect on first officer's im·erter Reader were removed and this had 10. ADF No. 1: Receiver went off no effect upon the operation of the distribution bus-bars or at some unit was on. (Inspection dis­ cuit bre:iker was opened, neither the warning light. In each instance, the other appropriate point as close as and there was no needle move­ closed this unit was equipped captain's nor first officer's warning ligh t came on immediately. C-2 gyrosyn compass. T he Zero ment. Reader fuses were replaced . practicable to the take-off point for with d.c. power supply incorpor­ light came on. When Phase C cir­ the feeders to the fligh t instruments. ating dynamotor) . cuit breaker was opened, the warn­ Emergency Inverter The Phase A fuse of the captain's T he failure of a flight instrument, or Phase C - Upper Inverter ing lights came on at once. 9. VOR No. 2 : This receiver was No. 2 engine was started and its instrument transformer primary was an open circuit in a feeder between Phase A circuit breaker of upper off. With the inverter selection again ~cn erator brought on the bus. removed, and the captain's inverter that instrument and the takecoff inverter was closed and time allowed set so the captain's .-light and engine Ground power was turned off and warning light did not come on at point for the power failure warning­ for gyros lo reach operating speed. instnun enls were on the upper, and inverters on (Captain's flight and tha t time. After waiting about 30 device, generally will not result in Phase C - Lower Inverter Phase C circuit breaker was opened: the fi rst officer's fligh t instruments engine instruments on upper, first ~econ ds , a hard right turn of 360° a warning of power failure. offi cer's flight.instruments on lower) . was executed. The needle of the 1. Captain's inverter warning light Phase A circuit breaker of lower on the lower, checks were made; The only method of obtaining a inverter was clcsed and time was Secondary voltage of .he captai n's The emergency inverter was turned turn and bank did not respond to positive indication of an instru ment came on at once. the turn. The C-2 and the course allowed for gyros to reach op eratin~ instrument transformer was measured on br gang bar, and flight instru­ failure under all conditions is to 2. Cap tain ·s gyro horizon tumbled speed. Phase C circuit Lreaker of between Phases A and C and found ments operated properl y wi th these indicators worked properly. T he have a warning device built into the 3 minutes later. Bar moved up lower inverte r was opened: to be 26 volts a.c. Allowing time for exceptions: captain's inverter warning light came instrument itself to indicate that the and to left, then to righ t and the gyros to reach operating speed, I. Compass card of captain's course on after 4.5 m inutes. The horizon gyro rotor is below the normal oper­ I. First officer's inverter warnino- tum bled 7 minutes after removing clown to centre in level attitude, • 0 the Phase A circuit breaker of the indica tor was jump){ and \\·oukl ating speed. Until such instruments 1 then moved up. C-2 slaving 1gh t came on at once. upper inverter was opened. The sec­ not rest on a heading. the fuse. The horizon bar fell off are available and installed, it should to the left. knob wa~ turned, but captain's 2. Power to A-12 gyro pilot was on. ondary voltage rose from 26 to 29 2. Vertical main pointers of Zero be borne in mind that the failure of course indica tor compass card \i\lith aircraft at rest, slaving volts and remained constant while Reader indicators m oved con­ Phase A fuse was replaced. The a flight instrument will not neces­ would not fo llow gyrosyn card. of co-pilot's course indicator being observed for 1.5 minutes. tinuously hack and forth. righl im·erter switches were unchanged sarily be indicated by the power 3. Zern Reader went off. Flag came card to A-12 gyrosyn compass to left. and all Phase A loads were removed failme warning device. up for vertical main pointer of could not be checked. Transformer Fuse Removal The Phase A fuse of the cmer­ rrom the upper inverter except the T ests are being conducted on all indicator and it would not re­ This check was repeated by re­ !.!;ency inverter was removed and captain's turn and bank and gyro aircraft having a.c. flight instru­ 3. First officer's gyro horizon tum­ horizon. T he Phase A circuit break­ ceive heading information from bled 6 minutes later. Horizon moving Phase A fuse of the captain's neither inverter failure warning ments to determ ine the effects or C-2. instrument transformer primary in­ light came on. Fuse was replaced er of the upper inverter was opened. various faults in the distribution bar moved up while tilting to T he hor.1on bar tumbled to the left left. It then moved down while stead of opening the Phase A cir­ and Phase C of emergency inverter system to those instruments. The ap­ 4. ADF No. 1 came on, but no removed. Roth inverter failure warn­ after 10 m inutes and the captain's prcpriate operators will be advised pointer indicat·ion. still remaining ti I ted to left. cuit breaker of the upper inverter ; voltage in the secondary immediately ing lights came on at once. T he in\'erter warning light did not come of the results of these tests, and Phase C circuit breaker of lower emergency inverter was turned off. on. where necessary, the systems will be Phase A - Lower Inverter fe ll to 23 volts and began to slowly inverter was closed and time was fall from that value After 5.5 min­ T he circuit breaker was closed and re\'iewecl with the object of improv­ Phase C circuit breaker of upper allowed for gyros to reach operating utes, captain's inverter failure warn­ Heading Indications the Phase A loads were re-installed. ing the reliability of the power fail­ inverter was closed ; Phase A cir- speed. ing light came on. At that instant Remaining engines were started .-\ fter allowing time for the gyros to ure warning devices .

2 3 Collisions With Overhead Wires 2. DH.82 at Gilgandra-24.2.57 field and in the ea1 ly runs the pilot operations were continued without flew in over the cables and out be­ incident and the pilots then departed I )uring a period of dual instruc­ neath them. After a nwnber of such in opposite directions for night tion at a country aero club, the fli ght During the first ten months of 1957 aircraft in flight struck overhead wires runs had been completed the air­ accommodation. On the fol lowing ins:ructor took the aircraft in!o the craft struck them whilst descending morning one pilot approached the on 15 separate occasions. Five ·people lost their lives in these accidents, eleven authorised lo-w flying area and it into the field. The aircraft cart­ landing strip from the south with a others were injured and thirteen aircraft were either destroyed or substantially wa~ observed carrying out simulated wheeled and bw-st into flames. The following wind a nd he decided to damaged. Clearly, this type of accident is avoidable and this waste of lives and forced landings followed by low fly­ pilot was seriously injured. land in this direction. Not only did ing practice. The aircraft was flying he make a low approach but, when aircraft is disturbing in a country which has an accident rate among the lowest at about 35 feet when it collided in the world. Here is an obvious avenue for reducing it even further. he was a mile out and about 50 wi1h power cables carrying 11 ,000 6. DH.82 at Gatton-17.4.57 feet high, he noticed the other air­ volts. The cables were stretched Before commencing to spray a craft approaching the northern across a cleared area but the wooden threshold of the same strip. He Let us add some perspective to rcf::: rs to collisions with all manner The right hand si de of the table s11pponing poles w~re partly ob­ potato field in a DH.82 aircratt a pilot noticed a line of power cables elected lo continue the approach at Lhese bare fi gures. The following bar of stationary objects; a general trend refers to collisions with overhead scured by scrub. Both instructor and about 45 knots with sufficient power chart. summarises the Australian for these occurrences to increase both wires both in numbers and as a pro­ p upil were killed in the impact and across one end. He did not inspect • them closely but commenced spray­ to maintain level flight until the experience, since 1954, of airborne in numbers and as a proportion of portion of a ll airborne collisions the aircraft was des1royed by fire. other aircraft had landed and clear­ aircraft striking stationary objects. all accidents is evident. The in­ ing with the in tention of passing with stationary objects. Here again ed the strip. I t was during this stag~ creasing activity of the industry the trend of increase is repeated beneath them on each run. In some 3. DH .82 at Gatton-25.2.57 of the spans single cables had of the approach that the pilot sud­ The left hand side of the chart could be one explanation but the both in training and private oper­ denly saw the power cables immed­ ations and in agricultural operations. drooped close to the ground and the AIRBORNE COLLISION ACCIDENTS A pilot. wlto had recei,·ed sub­ aircraft struck one of these causing iately in front of him but too late Slightly more than half of the col­ stantial training in agricultural fl y­ to avoid them. T he aircraft was lisions with overhead wires occurred damage Lo the wing tip, but fo rtun­ ing 111ethods. was engaged in dusting ately. no injury 10 the pilot. badly damaged and the pilot re­ ~Q!..LISIONS WITH OBJECTS COLLISIONS WITH in agricultural operations but each a s1 11a ll fie ld of potatoes. A power cei\'ed facial injuries. WHILST AIRBORNE QYERHEAD WIRES group has contributed to the annual transmission line 30 feet high on increase in accidents of this type. wooden poles ran along its eastern 7. DH.82 at Nanangroe-16.5.57 I t is also interesting Lo note that, of Tot•I Total boundary and the pilot carried out 9. DH .82 at Binnaway-29.5.57 all all the eight deaths which have occurred An experienced agricultura l pilot Accident5 Collis1ons his rnm heading north or south. in the past four years from collisions The final two nms along the head­ had been spreading superphosphatc An agricultural pilot commenced his first take-off for the day. The 1954 136 21 19&4 with overhead wires, only two have land strips had to be made east and on a larg-<' country property for over occurred in agricult.ural operations west and, on the first of these. the four weeks. The property, being close strip was dry, hard, 2,400 feet long and there was a head wind of 5 whilst th e remaining six, including pilot misjudged the pull up point to a hydro power generating station, knots. The aircraft was loaded with 1955 20l 19% 38 1955 fi ve deaths this year, have occurred and hir th e cables with the port was criss-crossed with power lines superphosphate and failed to clear in private or nying training opera­ interplane st ru t~. The uncomcious carried at· quite a variely of heights tions. pilot was p11llPcl from the wreckage above ground ltTel. At about mid­ a power line 10 feet high crossing 1956 197 171 33 1956 the sout_h western end of the strip. Twenty-six percent of a ll accidents ju ~ t bl' fore I he aircraft was con­ af tcrnoon h<' was returning to the The mamplanes struck a supporting this year have involved a n airborne s11111cd b,· fire. landing fi1 ·kl flying at about 50 feet abm·e the gene1al level of the ter­ pole and the aircraft was extensively 50 1957+ collision with a stationary object and over one-third of these have rain in ord<'r to minimise the effect damaged. The pilot escaped without been with overhead wires. Some of 4. DHC.1 at Casino-23.3.57 of slight turbulance. Close to the injury. 50 40 30 zo 10 0 10 zo these accidents are publicised else­ strip he had lo cross power cables A pri' all' pilot took an aero club + 1957 f19ures are tst1mate s for IZ "months based onihe experience of the first 10 mon+hs where in this or in other Digests but, strung on poles. 35 feet high and Chipmunk aircraft from a country l 0. DH .82 at Derrinallum-1.6.57 for convenience, in the following 1.200 feet apart. He saw the cables ~ Accident& occuf'T'in9 in Agricu1tur.J1 Operations centre and did a low level " beat-up" table we put them a ll together in­ too late to avoid them and the a ir­ of a friend's house on a country A pilot of limited experience in Lota! of all types of accidents has re­ ations and the remammg portion cluding som e prel iminary informa­ craft crashed heavily to the groun d. low level agricultw·al work was en­ property. He had indu\ged in this mained at a fairly constant level over represents collision accidents in fly­ tion on accidents still under inves­ The pilot was very fortunate to es­ gaged in spraying weed killer along dangerous practice at the same spot Lhe past three years and Lhis suggests ing training and private operations. tigation. cape with minor injuries. on previous occasions but this time. the boundaries of country properties that the change in the pattern of You will notice that both groups to create grass fire breaks and Lo l . DH.82 at Lithgow-13.1.57 on 1he third pas~. he clipped the top accident types is a reflection of the have contributed almost equally to 8. DH.82 at Bungendore--22.5.57 limit the spread of noxious weeds. changing pattern of the industry's each year's accidents in this category An aero club pilot found himself of a fig tree near the house and col­ lided with power cables. T he pilot As might be expected, many of these activity. Low level agricultural oper­ and to the increasing proportion of out of reach of an aerodrome near When two experienced pilots ' boundaries were lined with power was killed on impact with the ations have increased sharply in the the category in the whole pattern the end of a cross-country flight and arrived at a station property to ground and 1he aircrnft \\'as burnl and telephone cables and this pilot past three years and. in the very of accident types. It is not easy to with the light rapidly fading. He was commence supcrphosphate spreading fl ew along and over these cables nature of this work, there is a pro-­ explain the increased number of col­ forced lo land his aircraft on the Ollt. in DII.82s. the\' carried out both an many times. On one run alongside pensi ty for airborne collisions. This lision accidents in private and train­ outskirts of a provincial city and, aerial and a ground survey of the cables 20 feet high and towards by no means contains the whole story ing operations but the circumstances during his approach to a sports 5. DH.82 at Lowood-2.4.57 area. Three power cables 30 feet rising ground topped by cables 30 of the rise in the collision accidents of this year's accidents suggest that field, he collided with telephone high crossed l he southern approach feet high he left the pull-up until as the bar chart illustrates. The wires lining a suburban road. The A pilot well experienced in agri­ to the landing strip 700 feet from the too late and the aircraft struck the private pilots arc not maintaining shaded portion of each bar repre­ aircraft was substantially damaged c11 h 1ral operations. was engaged to threshold. I t was decided to con­ cables and crashed to the g round sents the proportion of these acci­ the careful watch for obstructions and the p ilot and passenger suffered dust a field of potatoes with sulphur. duct all take-offs towards the north inverted. The aircraft was substan­ dents occurring in agricullural oper- which flight at low level demand s. facial injuries. Power cables 26 fret high were sus­ and landings towards the south to tially damaged and the pilot received pended across one corner of the avoid these' rabies. For three days, serious head in juries. 4 5 11. Ryan S.T.M. at Corowa- the ground. Both the pilot and H ard experience has taught many 3 .8.57 passenger recein: fatal injuries. agricultural pilots to smYey operat­ Overseas Accidents The pilot of a R yan S.T .M . ing areas ca1·efully before getting descended to a low height in the clown to work. Careful preparation late afLernoon to inspect a field for 15 . DH.82 at Gawler-26.10.57 of this sort is being nullified by for­ Crash Following Missed Approach landing. H e fl ew across the field at T he aircraft struck power cables ~elfu ln ess or by deliberately flying 20 feet into the sun, closely inspect­ ·.vililst crop spraying. The aircraft too close to the wircs--better to dust ing the surface conditions and, as was badly damaged but the pilot or spray those last few yards from On 29th August, 1956, at approximately 2045 hours; a Douglas DC.68 he commenced to pull up over the escaped with m inor injuries. the ground than risk your neck and crashed following a missed approach at Cold Bay Airport, Alaska. Eleven trees a long the boundary. the air­ ai rcraft in this way. passengers, including one infant, and four crew members were fatally injured. craft strnck power li nes suspended Three passengers and four crew members received injuries of varying degree. Comment on wooden poles crossing the field. The aircraft was destroyed by impact and fire. T he aircraft crashed to the ground P ri\·atc pilots and instructors must These accidents emphasise that it on its back but the pilot and also appreciate the val ue of flying is almost impossible to see overhead The Flight approxim ately 40 degrees magnetic aircraft involved was 1,900 h.p. and passenger were only slightly injured. at a safe height or alternatively wires in fl ight in sufficient time to and 4,300 feet east-south-east of the 2,600 r.p.m. carrying out a p reliminary survey of T he aircraft was on a regular avoid them. If you must fl y al .. sched uled international flight from approach end of runway 26. T he the area before attempting flight at Ground witnesses testified Lhat danger height, survey the area first Vancouver, Briti s h Columbia, physical evidence indica tes that at 12. DHC. 1 at Kellerberrin- low leYcls. 1 t is wise lo profit from Canada, lo Hong Kong, China, the time of impact the aircraft was the aircraft, during its pass over from a safe heigh t looking for poles runway 14, was flying at an estimated 26.8 .57 the other fel low's experience-you with a refuelling stop at Cold Bay, descending in a slightly nose-down or lowers which m ight carry wires. Alaska, and an intermediate stop atti tude with the left wing down altitude of 100 - 120 feet above the A flight instructor landed a Chip­ \Ve can' t bury the wires but they may not have the chance of profiting at Tokyo, J apan. The aircraft, about 15 degrees. Computed ground ground, with the landing gear munk in a large open field and can bury you. frorn your ni 1111. which depar ted from Vancouver a t speed at impact, based on propeller clown, and landing lights on. later took-off in the same direction 134 7 hours, carried 14 passengers go,·ernor settings and propeller cuts T he company despatchcr observ­ commencing al the end of the land­ and a crew of eight. in the ground, was approximately 186 knots. ed the aircraft break out of the ing run. T he aircraft ran into soft A clearance was issued in accord­ overcast, appear to be making a ground reta rding acceleration and ance with an instrument flight plan The aircraft wreckage disclosed landing, and then he heard power a lthough it cleared the boundar y A Lesson Lea rnt fi led with Vancouver Airway Traffic no evidence, so far as could be applied. H e next observed the air­ fence the aircraft ran through a Control. Position reports received determined, of an in-flight struc­ craft turn to the southe:ist over the from the fligh t indicated that it was tural failure of the airframe or mal­ intersection of runways 14 and 26 telephone wire which the pilot did making good its track slightly ahead ftmctioning of its systems. There in a shallow climb. The despatcher T yson experienced a runaway prop on not sec. Minor darnage was caused Do you recall the article "Ground of the estimated t i.m e. At 2035 hours was no indication of in-flight struc­ held a microphone for V.H .F. radio No. I engine. T he prop broke free Effect" which appeared in Aviation it reported its position over the tural failure or malfunction of the contacts with the fl ight and was on to the mainplanes and the pitot/ and damaged the No. 2 engine, thus Safety Digest No. 9? I t was a re­ Cold Bay range station outbound engines, propellers or their related the point of asking iI the pilot sla t ic tube was pulled off but the forcing two engines out of opera tion. on a standard instrument approach, accessories. Examination of the pro­ wanted the lights switched to run­ aircraft continued with the flight to print from "The MATS Flyer" the D espite that, Major Tyson brought h is and the last transmission from the pellers and propeller governors in­ way 26 when he saw fire at ground United Sta tes M ilitary Air Transport lim ping C-97 to lower altitude and its desti nation without further mc1- flight was at 2042 hours when it dicated that the blades of all pro­ level. flew the 1000 miles to H ilo at an den t. services safety magazine. The appear­ repor ted completing a procedure pellers were at a blade angle of altitude of 100 to 150 feet. ance of that article in " MAT S'' was turn and proceeding inbound. approximately 40 degrees and that None of tlie ere,\· survi,·ors re­ directly responsible for preventing a " In a n inte1v iew, M ajor T yson the engines were operating at an called any aircraft operating dif­ C-97 T ransport aircraft from ditch ­ credited an article in 'The M ATS At approxunatcly 2045 hours the average speed of 2,460 r.p.m. at ficulties prior to the impact. T he 13. DH.82 at Narrandera-4.10.57 aircraft was observed !. to descend surviving stewardess testified that ing- the Captain has said so. T he Flyer' for his awareness of the bene­ the lime of impact. It was com­ This aircraft, in the hands of an fits of ground effect and his decisio n from the overcast north of the air­ puted that each of the fom engines she saw runway lights a short time following quotation from a Flight port for a landing on runway 14 before the crash. O ne flight crew e>qJerienced agricultural pilot, struck to take advantage of those benefits to was delivering approximately 1,385 Safety Founda tion Bulletin refers to bring his aircraft, crew and fif ty-seven and cross the field at a low altitude horsepower at impact, which is member who was resting in a crew power lines on the fi nal r un of a to the intersection of the two run­ the incident. pas~c n ge rs to a safe landing at H ilo." slightly more than cniise power. sleeping compartment stated that crop spraying operation. T he air­ ways. At th is point a shallow left T hr landing gear and wing fl aps power was changed frequently dur­ craft was extensively damaged and turn was started and the aircraft were determined to be in the up, or ing descent, and that the power " Proof of the value of 'The MATS The sole purpose of "The M A T S tlw pilot seriously injured. Flyer' if add itional proof there need went out of sight south-east of thr retracted. positions at the time of applied for a missed approach be, was evidenced in the recent accom­ F lye r'' and other safety magazines is airpon. Very soon thereafter fi re impact. seemed less than uormal. H e also plishment of Major Samuel Tyson that of ed ucat ion. Tn this one "sa\·e" was obser\'ed in that direction. said that he thought there ·was a and his crew who brought their great T hl' MATS Flyer has proved its T he operator's manual, according feeling of "sink" just before the 14. DHC.1 at Canberra-20.1 0.57 to testimony of the chief pilot, C-9 7 safely to Hilo, H awa ii, after value. If you are a " light reader" Investigation ground contact. The duty navigator, specifies that, in the case of a missed who was unable to see either out­ An aero club Chipmunk flown by more than 1,000 miles of flying on we would recommend that you just two engines. Soon after passing Examination of the wreckage and approach. METO power is applied, side or the two pilots because of a a p rivate pilot with a passenger the point-of-no-return on a fl ight from carefull y read all safety p ublications ground marks disclosed that the the gear is retracted, and the flaps black-out curtain between his seat aboard struck overhead wires in the T ravis Air Force Base, California to that come your way. T here m ay be aircraft first struck the ground at an are retracted to 20 degrees for th<' and the pilots, testified that he over­ C lub's training area al)d crashed to Hickham Air Force Base, O ahu, M ajor a save in them for you too. elevation of 10 feet on a heading of climb-out. METO power of t·he heard one pilot say, "No, Phil"

6 7 when power was being applied over Analysis with wing flaps extended 20 degrees, right turn "·hich the tower im­ The crash site was about 13 miles later study of some of the recovered runway 14. He also observed a I t is probable that the intention also when the aircraft passed over mediately granted. There was no northeast of the Albuquerque Air­ components of the aircraft. showed reading of 160 feet on his altimeter of the pilot during the approach was runway 14 it was in landing con­ further radio contact with the air­ port and almost directly on a no evidence of fire or structural which being set at 29.92 produced to land on runway 14, a straight-in figuration. Since only slightly bet­ craft. slraight line course of 30 degrees failure prior to impact, nor of mal­ a reading approximately 30 feet landing from the inbound over­ ter than cruise power was applied magnetic from that airport ( eleva­ functioning of either engine or either The tower operators last saw the tion 5,340 feet m.s.I. ) to the Santa propeller. A study of recovered higher than true. heading of the range station. The at this time, and as the distance to aircraft south of the airport at an breakout, after descending through the point of impact was approxi­ Fe Airport (elevation 6,344 feet radio components disclosed ' that No. The Cold Bay Airport has an altitude of 500 - 600 feet. Take-off m.s.l. ) . Elevation of the site was I VOR Navigation Receiver was the overcast, may have been too mately one mile, it is unlikely that appeared normal. · elevation of 93 feet. The two run­ close in and high and these factors, the airspeed of the aircraft would 9,243 feet m.s.I., some 1,439 feet tuned to the frequency of the ways 14 - 32 and 26 - 8 are 7~500 together with excessive ground speed have been much greater than 140 One highly qualified obsen·er, at lower than the crest of the ridge a Albuquerque Omni Range Station; feet and 5,000 feet in length respec­ due to a quartering tailwind may knots when the flaps were retracted. his residence about three miles north mile or so directly ahead. No. 2 VOR Navigation Receiver tively, and intersect on the south have caused the captain to decide As the subject aircraft was in a (magnetic) of t11e airport, saw the was tuned to the frequency of the side of the airport. The control to go around. clean configuration (gear and flaps aircraft proceeding directly toward At 0708, about five minutes before Albuquerque ILS Localiser. Other tower was not operative and there Although the missed approach up) immediately prior to the the middle of Sandia Ridge. This the crash, the Albuquerque weather navigational instrwnents were either was no C.A.A. Communications procedure at Cold Bay prescribes accident, with a tailwind of approxi­ man, an Air Force Officer-Pilot, was officially recorded as: 4,000 not recovered or were so extensively Station available. The facilities of a climb to 2, 700 feet on the north mately 20 knots it would be reason­ • thought the course was so unusual feet scattered, 7,000 feet thin damaged that they could not be one of two private air-ground com­ leg of the range, the company able to assume that the speed of the that he watched the flight with broken clouds; visibility 40 miles; tested nor their settings learned. munications stations on the airport despatcher, who observed the air­ aircraft increased during the final binoculars. It passed over the wind S.S.E. 6; altimeter 29.82; were utilized by the operator to mountains obscured northeast. The This aircraft was equipped with craft and was in radio contact with descent. Therefore, the initial speed eastern part of Albuquerque, near a Hughes Terrain Warning In­ relay position reports, and to receive it, thought that the Hight intended of 140 knots plus the speed gained him, at an estimated altitude of Santa F, 0628 regular sequence traffic clearances, weather informa­ weather report gave: Estimated dicator, which simultaneously flashes to circle under the 500 feet ceiling during the descent, toge"ther with 3,000 feet ( 8,300 feet m.s.l. ) in a a light and sounds an alarm when tion and local traffic conditions. and land on another runway. He the 20 knot tailwind, would result high-speed shallow climb. He noticed 3,000 feet broken ; 20 miles visibility; wind southwest 9. Before departure the aircraft is 500 feet. 1,000 feet, was about to ask the flight if they in a speed on impact approximately that the upper portion of Sandia or 2,000 feet from am· obstruction, Navigation facilities in operation wanted the other runway (26 - 8) equivalent to that deduced from the Ridge was obscured by clouds. The the pilots had been briefed on the at Cold Bay include a private owned weather, which was generally clear as set. The obstructioU: may be any­ lighted when the crash occurred. propeller cuts on the ground. aircraft continued its heading, to­ where downward from witl1in about (Reeve) non-directional beacon, Considering that very little altitude It is evident that the aircraft ward the ridge, and was lost to his and would have permitted visual which is located off the approach flight O\·er nearly the entire route, 5 degrees of the horizontal in all was gained after the application of struck the ground while descending view as it l'ntered the cloud, within directions - ahead astern. or to end of runway 14 and operated on power it is probable that a circling in a slight left turn and while all two or three miles of the ridge crest, with only short instrument flight pro­ request only. No such request was bable. This condition was actually either side. In other words, it covers aproach had been decided upon four engines were not operating at still in shallow climb. The engines a space of almost a complete hemis­ received from the aircraft. when the left turn from runway 14 the prescribed power settings neces­ sounded normal. encountered hy another aircraft over the same route that departed phere below the aircraft. Qn the The airport is equipped with a was made. It is believed that the sary to execute a missed approach last previous flight of th is aircraft wing flaps were retracted shortly be­ procedure. The flap retraction with­ One other witness, who observed Albuquerque 11 minutes later. rotating beacon and high-intensity the aircraft at about the same time the T errain Warning Indicator had runway lights that can be operated fore impact. This would explain the out a compensating increase in The TV towers on the highest been functioning and it was one of feeling of "sink" experienced by the power, or change in attitude or and place, watched until it. dis­ on only one runway at a time. Dur­ appeared in the cloud, headed to­ point of Sandia Ridge had been the items checked, and found to be ing the fli ght's approach the high­ off-duty Hight crew member. combination thereof, caused a sub­ ,·isiblc from the Albuquerque Air­ working properly during the pre­ The investigating authority be­ stantial loss of lift resulting in a ward Sandia Ridge. There were no intensity runway lights on runway known witnesses to the crash. port at 0625, approximately 43 flight inspection just before the 14 and approach lights to the run­ lieves that the airspeed of the air­ loss of altitude. minutes before the crash, by official final take-off. way were lighted and operating nor­ craft at the time the flaps were re­ When the flight did not report \\leather Bureau observation. How­ mally. In the vicinity of the air­ tracted wa•; approximately 130 to Probable Cause over the Weiler Intersection, short­ cver, at the time of the crash the port, and in the quadrant in which 140 knots. This is supported by It was concluded that the pro­ ly after 0712, the tower asked the upper portion of the ridge was Analysis the aircraft was flying when the several facts. According to company bable cause of the accident was the flight if it was northbound on the obsrnred by cloud. accident occurred, there were few, procedure it is normal on the down­ full retraction of the wing flaps at back course (of the ILS localiser) . The aircraft took off at 0705 and if any, lights which would assist ir. wind leg of an approach to a run­ low altitude during a circling ap­ There was no answer. Repeated Fire followed impact, which is be­ the only indication of the actual orientation. The reported ceiling way for the aircraft to fly at an air­ proach without necessary correctiYe subsequent calls were unanswered. lie,·ed to have occurred while the crash time is the watch found im­ and visibility at Cold Bay at the speed of approximately 140 knots action being taken by the crew. A search was started· by 0830. aircraft was in a left climbing turn. pact-stopped at 0713. If we assw11e time of the let down were the speci­ Clouds hampered search for the re­ \'\'rcckage was widely spread over that this tells the duration of the fi ed landing minima for the opera­ mainder of that day. About 0942 the extremely rugged mountain in fl ight as eight minutes, it is evident tor's DC.6 flights, viz. 500 feet and the following morning the wreck­ the general direction of about 320 that the aircraft was flown straight 1-3; miles. age "was sighted from the air just degrees magnetic. One wrist watch from the airport to very near the crash site for there was not time to below the crl'st of Sandia ~1ountain. was recovered: iL was i1npact-stopped The pilot had been qualified as a Martin 404 Strikes Mountain at 0713. One altimeter was rc­ do much more than tra,·erse the captain on the operator's domestic CO\'ered: its setting was correct for intervening 13 miles. The testimony ( Based on re/1ort of Civil Aeronautics Board, U.S.A.) lines for over 10 years prior to Investigation the t irne and place of take-')ff. of ground witnesses confirms this assignment to the Overseas Division straight course. and his total Hight time was 12,782 A Martin 404 struck Sandia Mountain, near Albuquerque, Shortly after the aircraft was Initial inYest igation at the scene The magnetic course from hours, which included 465 hours in New Mexico at 0713 hours on 19th February, 1955. All assumed to be down all C.A.A. was greatly handicapped and cur­ radio facilities that could have been tailed by deep snow and inclement Albuque1que to the crash site (and DC.6 equipment. Jn accordance 16 occupan~· s were killed and the aircraft was destroyed. 1 was Company policy, this flight was in\'oh·ed were flight checked. All weather and had to be abandoned. to Santa e) is about 30 degrees being accomplished under the super­ The Flight number of scheduled stops, the first were found to be functioning nor­ Careful planning went into the and the wreckage was strewn in a vision of a captain already qualified The aircraft was engaged on a of which was Santa Fe, New M exico. mally, including Albuquerque Omni organisation of another expedition, manner indicating a direction of over the Vanco11v'!r - Hong Kong scheduled flight from Albuquerque The aircraft took off at 0705 hours Range and the Albuquerque which reached the site on May 3. flight at the moment of in1pact of route. to Baltimore, Maryland, with a and permission was sought for a Localiser. The results of their findings, and about 320 degrees magnetic while in

8 9 a left climbing turn. This means the airport lo the right, and picked likelihood would have to be accom­ closure of the airfield. The aircraft pine trees some 3,000 feet from the which made visibility variable and that the aircraft was turned to its up a north-east heading directly to­ panied by the crew not looking be­ remained at Nicosia for 1i hours and beech tree. uneven. left abuul 70 degrees from its ward Sandia Mountain instead of yond the cockpit. And further, all then left for Idris, arriving at 0515 original heading and climbed just pursuing a course along the airway these conditions would have had to hours on 5th November. The crew Fire broke out in the front of the The I.L.S. transmitters and before th!'! crash, as if Lo evade an to the west and north of the moun­ prevail continuously from the very had then completed a continuous aircraft and began to spread into beacons were found to be in order obstruction. tain. It was contact during the turn start of the flight up until it was period of duty of over 19 hours. the fuselage. Considerable panic both before and after the accident. The pilot must have suddenly around the airport and for approxi­ within lwo or three miles of the ensued in the cabin, but most of the On the day after the actident a realised that he was practically at mately five minutes thereafter before crash site. ·This situation is thus At Idris it was necessary for the passengers were safely evacuated flight check was carried out in re­ the precipitous wall of the mountain entering the clouds obscuring the based on improbabilities compound­ crew to occupy emergency accom­ through the rear door, emergency lation to the glide path transmitter and acted quickly. We can only top of the mountain. ed to such an extent that the Board modation on the airfield where the exits being little used, although and the angle was found to be cor· conjecture as to whether this The possibility of malfunctioning m ust reject it as being too tenuous men's sleep was broken by noise passengers had been properly in­ rect to within 0.13 degree, an error realisation was spontaneous with the of navigational instruments having to warrant serious consideration as and, in som e cases, by cold. They structed in their use. Children passed within acceptable limits which would captain, or the first officer, 01 in· caused or being contributory to this a p06sible contributing factor of this were called at 1200 hours and the through an emergency exit o.n to a have caused a pilot following the duced by a warning from the accident was considered at great accident. captain prepared for departure wing, in the belief that they would indicated glide path to be slightly Hughes Terrain Warning Indicator length. In scrutinizing this possi­ which took place at 1525 hours. be safer outside, were burned to above the three degrees glide path. of an obstruction ahead, below, or bility it is necessary to keep in mind It is difficult to understand why Consequently, the crew had only death. Fire and rescue services re­ the flight took the heading it did The flight engineer was the only both. The realisation of the moun­ a number of factors. One is the ten how-s' " rest period" following sponded promptly and efficiently in survivor able to offer information tain ahead may, of course, have excellent visibility prevailing from from the airport to Sandia Moun­ the duty period of 19 how-s, where­ attending the scene of the accident, tain. However, there is no question regarding the management of the been brought about by something the take-off to a point where a com­ as the operating company's opera­ extinguishing the fire and bringing aircraft during the approach. He other than the Terrain Warning In­ petent witness saw the aircraft enter that if the flight had followed the tions manual specified the minimum the survivors to safety. prescribed clearance to the Weiler heard the captain inform control dicator, possibly a glimpse of terrain an overcast near the area of the rest period following 19 hours' duty that he would make an I.L.S. close below, or ahead, or both. crash. Under these VFR conditions, I ntersection the accident would not as at least 15 hours. Company re­ have occurred. T he evidence is approach. The descent from 4,000 Obviously an evasive manoeuvre crews are required by Civil Air presentatives stated that they would Investigation and Analysis feet to the airfield was at 1,800 was started. Regulations to be visually alert. clear that if an instrument mal­ expect the captain to exercise dis­ function occurred during the VFR The accident occurred on a night r.p.m. and 30 inches of boost. The The course flown was off airways There is no understandable reason cretion in disregarding the precise when the visibility at Blackbushe was captain subsequently called for and was neither authorised by the why the pilots should have failed portion of the flight it should have requirements of this instruction become quite evident ·to the crew poor. Arrangements had been made 2,100 r.p.m. and then for 2,400 Civil Aeronautics Administration nor to detect, by reference to con­ under abnormal circumstances, for the ascertaining of R.V.R. (Run­ r.p.m., the latter being considered sanctioned by the company. The spicuous terrain features, that they and by looking out they would have along lines similar to the instruc­ been sufficiently forewarned that way Visual Range) i.e., the distance normal for an approach. The cap­ correct and only permissible course were flying other than the planned tions which allowed extension of the along the runway that a pilot should tain then asked for 35 inches of is via Victor 19 airway, which skirts course, had they been alert. If we the previously planned and approv­ previous day's duty period beyond ed course was not being followed. be able to see the runway lights at boost, and later for 25 inches of Sandia· Mountain to the west by are to believe that undetermined the normal 16 hours. I t appears the point of touchdown. The method boost, after which he took over the several miles. The airways distance malfunctioning of the aircraft's that the captain wished to complete throttles from the flight engineer Probable Cause depends on a line of goose neck between Albuquerque and Sante Fe navigational equipment led the flight the fl ight without undue delay, and flares situated on the south side of and increased the boost to 30 inches is 53.5 miles; the direct course is into the crash area we must pre­ that he shrired the view of surviving The Ro.arc! determined that the the runway which are observed from for a few seconds, then to 3 7 inches. 43 miles. This difference of 10.5 sume a number of instrument members that a longer stay offerf'd probable cause of this accident was an observation point just north o.f A few seconds later the initial impact miles would amount to only about failures - failures which would be little prospect of real rest. a lack of conformity with prescribed the runway. The observer notes occurred. 3 - 4 minutes' difference in flying more or less simultaneous, of similar en-route procedures and the devia­ The flight from Idris proceeded how many flares he can see, multi­ time. However, the flight departed magnitude, and in the same direc­ tion from airways at an altitude too The r.p.m. and boost called for normally until the aircraft was plies the figure by 100 and so Albuquerque on schedule and if it tion. Furthermore, this extreme un- low to clear obstructions ahead. were considered to indicate nothing had been flown according to the approaching Blackbushe after being obtains the R.V.R. in yards. After exceptional, except that 25 inches of flight plan would have arrived· at cleared there by the Southern Air the accident, tests disclosed that the boost is rather a low figw-e and T raffic Control Centre, shortly after system at Blackbushe did not give Santa Fe , n time. 1 would result in a steeper descent \l\Tind velocity over the Sandia 2300 hours. The flight was in radio an accurate result, due partly to in­ than is usual when using I.L.S. Mountain was indicated to be ILS Approach Accident at Blackbushe communication with Biackbushe Air­ accurate placing of flares, and partly However, the higher rates of boost port from about 2334 hours to 2351 to some other factor, possibly too lig'llt {o produce an important ( This summary, fnepared by the M inistry of Transport & Civil A viation, called for later are not such as to hours, during which tirhe the air­ diminished intensity or altered beam­ " mountain effect" such as severe L ondon, is based on tlie re,bort of the Public I nquiry into the indicate that any emergency action craft was passed QFE.1021 milli­ ing of the runway lights. The effect turbulence, down draughts, and Causes and Circums_tances of the A ccident) was being taken. At · no stage did erroneous al ti tu de indications. bars, m ade routine reports of descent of the discrepancy in this case was the captain indicate that he thought to 1,500 feet and interception of that the R.V.R. was given as 1,200 Furlhermme, such effects when pre­ Shortly before midnight on 5th November, 1956, a j that anything was amiss as the flight sent are manifest over the crest and the outer marker and was cleared Lo yards when it should have been 920 engineer would have expected of lee slopes, whereas this accident Handley Page Hermes aircraft crashed while approaching land on runway 08 after reporting yards. However, a reduced minimum him from previous experience. occurred on the windward slope. to land at Blackbushe Airport, Hampshire, at the con­ the runway lead-in lights in sight. of 800 yards had been approved just The captain in command of the clusion of a flight from Idris Airport in Tripoli. The captain The captain was almost certainly prior to the accident and, although Wreckage investigation showed using the I.L.S. (Instrument Land­ his company's operations manual the captain's altimeter to be too flight was well experienced over the and two other members of the crew of six, and four route Albuquerque to Santa F e. In ing System) . The aircraft undershot had not been amended, the captain much damaged for any conclusion addition, the weather was such that children from among the 74 passengers, were killed. the runwav and hit a beech tree of the H ermes was almost certainly to be drawn from it. The first 3,617 feet ~hort of the threshold at aware of the reduction. An im­ cfficer's a'.timeter was set to 1,023 visibility along the airway was good The Flight remainder of the forwa1·d flight and a stage of the approach when it provement in visibility noted by the millibars. the navigator's to 1,022 for many miles ahead to the north. Early on 4th November, the air­ the return flight to Rlackbushe, should have been 197 feet above R.V.R. observer found no parallel and the flight engineer's to 1,023. I t The base of the mountains was clear­ craft had been flown from Black­ came on duty. D eparture for Nicosia, ly visible from the airport although bushe to Malta where, immediately the tree. I ts port wing was damaged in other visibility observations and is considered that these last three Cyprus, was delayed for over 4! by this impact and it swung sharply indicates that there was probably altimeters were set very close to the crest was obscured. The flight on its arrival a t 1000 hours, the hours by magneto trouble and, fol­ to port and finally came down among patchy and shifting mist or fog these figures before the accident took off from runway 11, circled crew, which was to complete the lowing- rectification of this, by

10 11 although all were damaged and the the first officer, depending on the bably tired enough to make their half the runway the captain de­ unloading valve. This valve will the aircraft to accelerate. Further, shock may have altered the settings allocation of cockpit duties) made mental reactions slower and less cided to carry out a go-around. At not permit a flap extension beyond 300 feet of altitude would have to slightly. So far as could be ascer­ one or more of the following accurate than they would normally this stage the aircraft was in the air 35 degrees with full flap selected be sacrificed during the flap retrac­ tained from examination of the errors:- have been. In view of the circum­ and at an indicated airspeed of and throttles fully retarded unless tion. Thus, it is evident that on altimeters, the captain's airspeed in­ stances which preceded the return 100 - 105 knots. Take-off power was the airspeed of the aircraft is at 120 single engine approach with full (i) failed to set his altimeter dicator and climb and descent in­ flight, it is impossible to say that promptly applied, the undercarriage knots or less. As airspcetl is de­ flaps, the aircraft is committed to correctly when given the dicator, and the l.L.S. control unit the captain was to be blamed for raised and the flaps retracted to the creased, the flap extension is pro­ a landing when below 300 feet. T he Q .F.E.; and indicators, all the damage sus­ his decision to take ofT without take-off position, 12 degrees. How­ gressive until full extension, 45 company's flight operations manual tained was consistent with impact (ii) gave up reference to his further rest, or even that it was the ever, as the flaps were raised the degrees, is reached at or below 104 did not contain a baulked landing or shock damage. I.L.S. indicator before he wrong decision to take off in the aircraft settled and the airspeed de­ knots with the throttles fully re­ procedure and very little training had a sufficiently clear view circumstances. creased. The aircraft commenced tarded. Whilst the approach flap or information was given to pilots The flight engineer's evidence of the lights; to veer to the left and its left wing setting of 24 degrees can be obtained regarding a go-around on one pointed to the aircraft having Probable Cause lowered. Seconds later the aircraft at 120 knots, 10 degrees more flap engine. A company instructor-pilot come considerably below the glide (iii) did not check his height by struck the ground left wing low. extension can be attained at the testified tl1at perhaps the company path for some appreciable time be­ glancing at his altimeter. The Court concluded that the same airspeed by positioning the pilot training did not stress the most probable cause of the accident fore the accident rather than to a Investigation cockpit flap control in the full flap single engine baulked landing situa­ If any of these errors was made was that, in difficult conditions and tion enough prior to the Las Vegas sudden dive. The magnitude of the it was probably due, at least in part, position. while su ffering from a degree of Ground marks showed that the accident. He added that this was eventual departure from the glide to some loss of alertness brought 1. fatigue above the normal, the cap­ left wing tip of the aircraft made The captain stated that he did probably because the programme path was such that, if the captain about ·by fatigue. The evidence had been aware of it, he could hard­ tain, relying on his vision of the the initial contact with the ground not call for full flap prior to reach­ intended to teach pilots to make suggests that, while the officers were J ing the runway threshold as the ly have been indifferent to it, and airport lights to assess his height, and this was followed closely by the the single engine approach and not suffering from any extreme speed was in the order of 120 knots it seems most likely that he was judged his height to be higher than left engine nacelle and aircraft landing without overshooting. He degree of fatigue, they were pro- and he was under the impression unaware of it. The l.L.S. indicator it actually was. · fuselage. T he aircraft then slid on stated that this proficiency and that the flaps would not extend and the altimeter, if they were its belly in an upright position for ability was expected of a line cap­ appreciably beyond the approach working properly and the altimeter 225 feet turning left around its tain and that in all the transitions position until the airspeed reduced was correctly set, must have given vertical axis through about 120 he had given in the Martin 404 over warning to the captain or the co­ degrees. The aircraft received un­ to about 105 knots. Following the a period of several years he had never series of attempts to force the air­ pilot. It is not known whether any repairable damage from the gr~n~nd seen an overshoot on a simulated arrangement existed for a division Martin 404 -Crash impact and the subsequent slidmg craft on to the runway the captain single engine. of duties between these two, and forces. The fuselage was i.early believed he would be unable to stop there is no evidence that any com­ -Las Vegas, Nevada separated parallel to the fifth row the aircraft within the remaining runway and decided to go-around. pany procedures existed to cover the (Based on report of Civil Aeronautics Board, U.S.A.) of passenger seats. Elsewhe1e, it Analysis nature and extent of the assistance \¥as twisted and buckled. The empen­ It was not possible to establish the to be given the captain by his first nage was relatively undamaged. point at which the landing was Examination of the port engine abandoned and for this reason it officer. On 15th November, 1956, a Martin 404 aircraft crashed Both wings of the aircraft were revealed that there h.1Ll been a buckled and the right wing was could not be determined whether failure of the No. 2 cylinder ex­ ~t McCarr~n Field, Las Vegas, Nevada, during an attempted The critical height below which broken chordwise just outboard of or not the aircraft could have been haust valve push rod. The ball end the pilot should not have come single engine go-around. The captain, the hostess and 14 its engine nacelle. The left engine brought to rest within the length of assembly of the push rod was found without having the airfield lights of the 35 passengers received minor injuries and the was found· turned outboard 40 the runway. to be loose and the space between clearly in view was 400 feet. The aircraft was damaged beyond repair. degrees by forces which bent and The captain testified that at the the push rod and the ball end was R.T. log indicated that the captain broke its engine mounts. T he right time he decided to discontinue the broken into several pieces and com­ pletely displaced. The end of the had, or believed he had the approach The Flight engine was turned out during initial landing and execute the go-around of the emergency and the aircraft push rod was worn with pieces lights in sight when he was still tmned towards the airport. forces as the aircraft slid forward he was firmly convinced that the about two miles from the threshold. The aircraft took off from Mc­ on the ground. This engine was performance of the Martin 404 on broken away. The end socket was It is likely that very soon after this Carren Field, Las Vegas, at 1456 The aircraft entered the circuit rolled inward towards. the fuselage. single engine would enable him to belled out and polished. This evid­ he would see the threshold and run­ hours Pacific Standard Time on a on base leg and as it turned on to It then struck and penetrated the do so. He believed that ·such a go­ ence indicated that the push rod way lights and believe that he was regular public transport service from long final the undercarriage was right side of the fuselage door. This around was possible provided the failure occurred where the ball end getting from them a good indica­ Las Vegas to Los Angeles, Cali­ lowered md approach flap ( 24 unit was found lodged in the cabin airspeed of the aircraft was ap­ is press fitted to the push rod and it was the failure of this component tion of his height and direction. fornia. The weather in the vicinity degrees ) vas extended. The air­ flooring just ahead of passenger ~eat preciably above minimum control The variations in visibility in dif­ of Las Vegas was fine, unrestricted speed at this time was 120 - 125 No. 2. The main and nnse coh1- speed. He stated that the airspeed, which caused the port engine to fail ferent directions, and in the same visibility and wind calm. Some two knots. As the aircraft passed over ponents of the landing gear were when he initiated the go-around, was shortly after take-off. It was estab­ direction within short periods, are to three minutes after take-off the the runwa) threshold its alignment found fully retracted. The wing lOO - 105 knots and the minimum lished that the push rod failure probably resulted from an improper consistent with the existence of a port engine began to malfunction. and alt i tud . ~ seemed good; however, flaps were found in a slightly ex­ control speed of the aircraft under fit made by the company's overhaul layer of fog or ve1y low cloud, not The engine difficulty was in the to nearly all observers excessive speed tended position; however, numerous the existing configuration was 91 very dense and not evenly spread, form of an appreciable loss of was apparent. fractures in the hydraulic lines would knots. department. power, back-firing and engine on or near the ground. This pos­ have allowed the flaps to move from The push rod failure would cause roughness. Attempts tq correct the The performance characteristics sibly caused the pilot to see the The aircraft floated down the the position which existed at the the exhaust .valve to remain closed trouble were unsuccessful and when o.f the Martin 404 are such that in lights as being further away and runway a few feet above it. The impact. thereby trapping exhaust gases under heavy and visible vibration began the configuration existing at the at a greater distance below him than captain made several attempts to pressure which would normally be the port propeller was feathered. To protect the wing and flap time of the go-around it would be they really were. force the aircraft on to the runway dissipated through the exhaust port. Single engine operation was estab­ structme, the wing flap system of necessary to retract the flaps to the but each time it bounced off. After take-off position in order to allow Therefore. when the intake valve It is probable that the captain (or lished, McCarren Field was notified the aircraft had travelled well over the Martin 404 incorporates a wing 12 13 opened these exhaust gases would The importance of tra1mng in Cause Both propellers were subjected to been shut down and its propeller shut down. In this configuration enter the induction system of the this potential accident cause area is a strip exa:mination, including the feathered, the accident might have satisfactory single-engine flight could engine causing loss of power, back­ reflected by the Board's air carrier The probable cause was that dur­ units connected with the system for been avoided. Why this was not not be achieved. firing and engine roughness. statistical data. This showed that ing an emergency situation the cap­ feathering the starboard propeller, done could uot be determined. there have been nine accidents since tain failed to reduce speed during but no evidence of ·any pre-crash Comment The captain stated that the air­ Cause craft crossed the runway threshold 1946 involving an engine out or the latter portion of a single engine defect was found. The blades of Dove aircraft are the onfy known at an indicated airspeed of 115 - 120 engine malfunction during which the approach; this excessive speed re­ both propellers were in fine pitch. T he accident was the result of the aircraft with this type of instrument. knots, which was excessive and that pilot attempted to go-around after sulted in an overshoot and an at­ pilot mistakenly shutting down the port engine instead of the starboard A.N.O. 105.1.14.13.5.9 requires the 95 - 100 knots would be normal at overshooting. This data also showed tempted go-around which was be­ Analysis instruments to be rotated 90° so the threshold. It is not unusual to 80 accidents during the same period yond the performance capability of engine in which a serious mechani­ that the oil pressure gauge is· at the maintain a higher than normal in which overshooting was the prin­ the aircraft under the existing The evidence indicated that the cal fault had developed. This led approach speed in a single engine ciple causal factor. conditions. pilot shut down the port engine to a rapid Joss of height and al­ top. The dial lettering is to be approach. However, this speed instead of the starboard engine which though the pilot re-started the port suitably changed to allow easy reading. must be dissipated at a point when had developed serious mechanical engine the starboard engine was not the landing is assured and in time trouble. The pilot was experienced to preclude overshooting. The Board Dove Accident and had completed over 500 hours concluded that the captain did not flying as pilot-in-command of this DC 4 En-route Collision With Terrain properly judge his position. As a type. A factor which might give - New Forest, Hampshire, England rise to this mistake is the use of A DC.4 was totally destroyed when it crashed and result he continued with excessive burned 3-l miles east of Blyn, Washington, at approxi­ speed beyond a reasonable position (Summary based on rej1ort compiled by Ministry of Transport combined oil pressure/temperature gauges. These instruments are dup­ for a safe landing. Contributing to and Civil Aviation, London) mately 1719 hours Pacific Standard Time on 2nd March, licated, one for each engine, and 1957, while en-route from Fairbanks, Alaska, to Seattle, his misjudgment he believed that The Flight the fuselage. The port engine re­ with 115 - 120 knots he could not normally mounted side by side. Each mained in its mounting. Both pro­ instrument is marked "OIL" at the Washington. The aircraft carried a crew of three and get additional flaps beyond the A De Havilland Dove took off pellers were attached to their re­ two passengers, all of whom received fatal iniuries. approach extension. Although only from Cardiff Airport at 0825 hours top centre and, although annotated spective engines but only the port "LB/ 0" and "°C'', respectively, at about 10 degrees more extension on a July morning for Southampton propeller showed evidence of being The Circumstances timbered mountainous terrain ap­ could have been attained, this dif­ and 25 minutes later, when at or the bottom, the marking of ad­ The aircraft departed Fairbanks proximately in the centre of the under any power on impact. There jacent pressure and temperature ference and its cumulative effect about its cruising altitude of 5,500 was no evidence of fire. for Seattle at 0958 hours with an "on course" zone of the northwest might well have been the difference feet, the engines became un­ scales are not dissimilar (see photo­ A.T.C. clearance to proceed via leg of the Seattle low frequency .graph) . A fall in oil pressure in Snag, Haines, Annette and Port radio range, about 11 miles south­ between an overshoot and a safe synchronised causing considerable The engines were salvaged and the starboard engine would be re­ Hardy at flight levels between 120 east of the Dungeness fan mark­ landing. vibration. The port propeller then sent to the manufacturers for de­ corded by th· ~ left-hand pointer of and 95 on the various sections. The er. This leg of the range defines When the captain decided to go­ stopped rotating and the aircraft tailed examination. After replacing lost height. When it had descended the starboard gauge. It is possible estimated time interval was 7 hours the centre of Amber Airway • 1 around he believed the performance certain components which had been to an altitude of approximately 200 that a pilot, seeing the left-hand 44 minutes. The forecast indicated (controlled airspace) between the of the Martin 404 in single engine damaged in the crash the port feet the port engine was restarted pointer of th1~ starboard gauge fall­ that the weather would be fine for Dungeness intersection .and the would enable him to do so. He engine was mounted in a test bed and almost immediately afterwards ing could, in the stress of the most of the route with cloud in­ range station. The terrain in the thought that 10 - 15 knots above the and given a thorough testing. Sub­ moment, associate "left" with "port" the aircraft flew very low over a creasing around Seattle. vicinity of the range between this minimum control speed was sufficient sequently it was stripped for detailed and in conse.;iuence shut down the although the aircraft was on one line of high tension cables. With Routine position reports wei'e marker and Seattle rises to 2,100 examination. The results of the test sound port 1mgine instead of the passed and at 1240 hours the air­ feet. engine, it was in a deceleratinG con­ increased vibration the aircraft con­ and strip examination showed that failing starbo,trd engine. tinued at low speed over undulating craft reported over Haines and can­ dition, and the landing gear and 45 the engine was in sound working In this accident the pilot appears · The path of the aircraft during country and, after climbing slightly celled its IFR flight plan; inform­ degrees of flap were extended. All order. to have reali~ed his mistake and re­ the final seconds of the flight was to clear a ridge, lost height and ing A.T.C. that it would proceed of these conditions existed with no started the port engine. Unfor­ clearly defined in the heavy timber altitude to sacrifice. Based on these descended into a densely wooded VFR to Annette and file D.V.F.R. growing on the steep slope against The starboard engine had sus­ tunately, by this time the aircraft (Defense Visual Flight Rules) after factors the Board is of the opinion area. When very close to the tree tained considerable damage. When was down tu a very lqw altitude. which the aircraft crashed. T he that the captain's belief was un­ tops it banked to the left and the Annette and before entering the aircraft's first contact with the dismantled it was found that the Even then, had the starboard engine C.A.D.I.Z. (Canadian Air Defense reasonable. port wing tip struck a tree. After crankshaft had broken at No. 3 trees was at a point 650 feet from travelling a further 400 yards and Identification Zone). At Annette, the wreckage. From this point it The Board concluded that the crankpin. This failure had occurred a VFR clearance was obtained for striking the tops of several other before the crash as a result of a cut a level swath on an easterly training programme of the company trees the aircraft crashed. The pilot penetration of the C.A.D.I.Z. and fatigue crack which had developed heading, the width of its wing span, with respect to the single engine was killed instantly and the six pas­ U .S.A. Western Security Identifica­ at a plugged hole in the rear web into the steeply rising wooded slope baulked landing situation was in­ sengers were injured to varying tion Zone. adequate prior to the accident. This of No. 3 crankpin. Heavy scoring at an elevation of 1,500 feet above degrees. From Annette onwards the air­ mean sea level. The terrain im­ was reflected in the captain's de­ on the faces of the crankcase web and craft passed routine position reports cision and the Board believes this Investigation cap of No. 1 main bearing showed mediately ahead of the aircraft rose on schedule advising that it was to an altitude o.f 2,000 to 2,100 feet. was in a substantial degree respon­ The port wing-tip was the first that Nos. 1 and 2 cylinders con­ flying at 1,000 feet. At 1717 . hours sible for the decision. It is con­ p:i.rt to become detached and was tinued working after the crankshaft the aircraft passed a position report The airframe and engines were sidered that the type of situation found 400 yards from the main had failed. The crankshaft had run to Seattle as "Dungeness at 16 VFR severely damaged as a result of im­ which confronted the captain should wreckage. The cockpit was crush­ for a total of 1,2Q5 hours since estimating Seattle at 34". This was pact followed by intense fire. T he have been foreseen by the company ed and the passenger compartment manufacture including 619 hours the last contact with the aircraft. wings were torn from the fuselage and the performance capabilities of had been ripped open. The star­ since the last overhaul when a modi­ in its passage through heavy timber. the aircraft in such a situation fully board engine had been torn out fication designed to prevent failures Investigation Parts were scattered from the point covered as a training subject. and was lying about 15 yards from of this nature was embodied. The aircraft crashed in heavily of initial contact with the trees

14 15 craft entered instrument condiliou:., along the entire flight path, and '.ls level. The captain had flown this route for a considerable length of in a controlled airspace without re­ Australian Accidents much as 75 feet beyond the roam questing an l~R cle.ara~ce, it is t~e wreckage area. time and knew, or should have known of this requirement. opinion of the mvest1gatmg authonty Examination of the wreckage did In C:ne of the reports, the aircraft that the conduct of the flight was his first landing on runway 04. not reveal any evidence of mechani­ gave its position as being 30 miles haphazard and certainly not ~q~al Weather conditions at th(} time were cal difficulties during the flight. It west of Comox, British Colombia. to that expected from an a1rlme DC4 Damaged in Undershoot fine, visibility 12 - 15 miles, hazy was established that the aircraft was At that instant, R.C.A.F. radar captain. and wind 070 degrees 6 - 7 knots. intact prior to contact with the showed the aircraft to be ten miles In its efforts to determine the The approach path was apparently trees. Also, that no inflight ~re south of Comox. The investigat­ cause of this accident the investigat­ A DC.4 operating a scheduled Island are situated on bisecting normal until shortly after lowering occurred and that all the burrung ing authority have been unabl~. to ing authority studied the terrain in se1vice between Auckland and ridges and the ground off the ends the final 15 degrees of flap. At this occurred after the aircraft came to rationalise the reported position the area between Dungeness and Sydney on 9th December, _1956, of the strips containing the run­ stage the pilot realised he was lower rest. No defects or evidence of mal­ with the known position and, there­ Seattle. This route segment passes landed at Norfolk Island, an inter­ ways falls away steeply so that final than intended and instead of com­ functioning was found in the exami­ over the Miller Peninsula which is mediate stop, at 1643 hours local mencing to flare out over the thres­ fore can only conclude that the approach in each case is made over nation of the engines and it was cap~ain was unaware of his pre.cise located between two bays three to time. hold markers he would need to do quite conclusive from the nature of position. Examination of the fhght four miles apart on the southern ground lower than runway level. At so over the beginning of the pre­ the damage to the propel~ers that log revealed that it had not been shore of the straits of Juan de Fuca. The landing on runway 04 was the south-west end of the 04-22 strip pared area, that is the embank­ substantial power was bemg pro­ properly completed. Thi~ was c'?n­ While these two bays do not appear described by the pilot, in a report the ground falls away first in a ment. No corrective action was duced by all engines at the time of trary to company regulations which to be similar when projected on a submitted at Sydney, as a heavy steep faced embankment some ten takef! as he judged the touchdown impact. It was concluded from the require this log to be filled out com- chart, it is believed possible that at landing without dropping onto the feet high and then in a gradual would not occur until the aircraft examination of the wreckage that pletely while en-route: . low altitude and in a slightly hazy ground but more in the nature of natural slope until, at a distance of had passed the threshold markers. the aircraft was being operated in A number of eyewitnesses m the atmosphere a pilot in a cas~al flying onto the ground. The land­ 200 - 300 feet from the embank­ After flare out when at a position the cruise configuration. Dungeness area saw t.he aircraft _just g l anc~, seeing only one or P'?rt1on ing was concluded in a normal ment, the ground is 20. feet lower judged by the pilot to be just be­ A number of persons saw the air­ prior to the crash flymg at a height of one of these bays, could mistake manner. On arrival at the terminal than runway level. This approach yond the embankment but short of craft shortly before the accident. of 1,000 to 1,500 feet und ~rneat h it for the other. area a member of a supernumerary area is overgrown with vegetation the threshold markers, the aircraft All these witnesses state that the a low overcast. All these witnesses It was found that if the aircraft crew aboard the aircraft reported to which extends up the embankment touched down. aircraft apeared to be operating stated their attention was drawn to had been approximately three miles the pilot the presence of a skin and the presence of the almost normally. The aircraft was i~ r~­ the aircraft because of its unusually east on a parallel course it would wrinkle on No. 3 engine nacelle sheer face may not be readily ap­ An examination of the embank­ gular radio contact up to within low altitude. The witnesses all have passed over Port Discovery, the cowling. The wrinkle was drawn to parent from an approaching aircraft. ment, made after the damage to the a few minutes of the crash. Had describe a distinct line of clouds more eastern bay. It was also noted the attention of the maintenance Runway 04 and its surrounding aircraft was discovered, showed that anything been amiss with the air­ below the overcast and lying direct­ that the terrain over which the flight engineer in attendance and an in­ strip are grass covered and, there­ the starboard main under-carriage craft up to this time, it is expected ly across the flight path of the air­ would have flown from this point struction to inspect dents on both fore, offer little contrast with the wheels had contacted the face of the that it would have been reported. craft. This cloud was described as on the way to Seattle was much sides of No. 3 engine nacelle general appearance of the surface in bank 12 inches below the top. These From the evidence of the eyewit­ obscruring the tops of foothills less than 1,000 feet. It was further cowling was entered in the main­ the approach area. The runway wheels had torn through the lip of nesses absence of reports from the which rose to 2, I 00 feet ahead of noted that the terrain between tenance record. The maintenance was defined by cone markers com­ the bank and for a further 24 feet aircraft of any malfunctioning. or the aircraft. Washington Harbour, the more engineer cleared this entry in t11e mencing 200 feet from the embank­ had left heavy depressions in the emergency and from the ex~urun~­ Two of the eyewitnesses stated western bay, and Seattle rose to an oppropriate column of the record ment and spaced at 300 feet inter­ strip surface. The port wheels and tion of the wreckage, the mvesl1- that the aircraft entered the cloud altitude of about 2,100 feet, a fact with a coll?ment that an inspection vals on each side. Corner markers, nosewheel had contacted the bank gating authority considers it ~·ea~on­ obscuring the hills. One of these of which the captain was undoubt­ of the cowl revealed no fractures. comprising a pair of eight feet long about two inches and one inch able to presume that no mfhg_h t witnesses reports that he heard and edly well aware. He also apparently advised the pilot gable markers set in the form of an from the top respectively. emergency existed and that the a1r­ felt an explosion several seconds It is, therefore, considered pro­ that he had noticed the wrinkle "L", one group each side of the craft was operating normally until after the aircraft had entered the bable that the captain mistakenly when the aircraft passed through , runway at the first cone markers, The extent of the damage to the it struck the ground. cloud. At this time the aircraft was identifi ed Washington Harbour as Norfolk Island on the outbound · defined the end of the runway and aircraft suggests, on first considera­ Along the route segment from in a controlled airspace and should Port Discovery and thinking he was flight earlier that day. While the the landing threshold. The effective tion, that the landing impact must Point Hardy to Patricia Bay, the have requested an A.T.C. ~l~aran~e three miles east of his actual posi­ aircraft was being 'refuelled the operational landing length available have been of such magnitude that aircraft reported its altitude as before entering IFR cond1t10ns m tion entered the overcast at an alti­ pilot examined the main landing was 5,300 feet which was 760 feet the pilot should have suspected that 1,000 feet. In order to ~ave been this area. No such request was tude which he thought was sufficient wheel tyres and found no marks on in excess of the required length damage had occurred and should at this altitude, the flight path made. Lo clear the ground. The investigat­ them indicating that the landing determined from the DC.4 landing have ensured that a detailed· exami­ would have had to follow a meander­ Both pilots had been employed by ing authority concluded that the had been heavy. weight chart. The markers were nation of the aircraft was carried inrr course over water at times as the company for many years and laxity and inattention exhibited by painted white and were clearly out at Norfolk Island. However, the m~1ch as 25 miles off course. Radar had considerable experience on the crew throughout the flight, The flight continued to Sydney in visible against the green of the grass forces applied to the aircraft in this determination and qualified eye­ DC.4 aircraft and were well quali­ lends substantial credence to this a routine manner but, during an covered strip and runway. There occurrence would have a large witnesses place the aircraft approxi­ fied over the route involved. Prior presumption. inspection carried out there prior to were no markers between the run­ horizontal component whereas a mately on course and at an altitude to the subsequent flight they had further flight, extensive damage to way corner markers and the pilot judges landing impact primarily of 2 500 to 3,000 feet above mean received a rest period of 26} hours. Probable Cause the internal structure of the inner embankment. by the vertical loads experienced. wing was discovered. Some de­ sea ievel. It is, therefore, obvious The probable cause of this that the aircraft was reporting its Analysis formation of the nosewheel - well The pilot, who had almost It is apparent that the pilot mis­ From the evidence that the accident was a navigational error structure indicated by skin buckling 10,000 hours flying experience, in­ judged the approach, probably due height above the ground. This :was and poor judgment exhibited by the contrary to C.A.D.l.Z. regulat1oi;s altitude was incorrectly reported, was also discovered. cluding 2,400 hours on the DC.4, to an illusion created by sloping that the Comox position was incor­ pilot in entering overcast in a had landed at Norfolk Island on ground off the approach end of the as flights in a defense zone, as this mountainous area at a dangerously was at that time, are required to rect, that the flight log was not pr.o­ The two runways at Norfolk four previous occasions but this was runway, resulting in the landing low altitude. report height as above mean sea perly completed and that the rur- 16 wheels striking a bank short of the pilot always aims to touchdown as of the desired track. Although this 72 miles to Temora and then alter­ judgment and caution were affected the accident was caused by the runway threshold. close as possible to the threshold it should have indicated that a sub­ ed course to port and crossed his in the approach to the area chosen, pilot attempting to take-off under is inevitable that on some occasions stantial starboard alteration of course intended track without fully ap­ by physical and nervous fatigue, conditions of aircraft load, length he will touchdown short of it. would be necessary, the pilot con­ preciating his position until he saw coupled with a realisation that the of· run and tail wind which pre­ Comment tinued in the same direction, hoping the reservoir on the Lachlan River. area was not really suitable for a cluded a safe margin of clearance This induced him to alter his in­ landing. There was no time to over the fence being obtained. I t is not only unsafe to try to land to find Katoomba and thence ap­ In the larger type airline aircraft tentions and, incidentally, to lengthen search elsewhere and the fading neatly on the threshold, it is unneces­ pr?ach Bankstown over familiar ter­ currently in use, and flown in accord­ light would make it difficult to dis­ T he pilot's flying experience was sary. T he required runway length as rain. his route to Sydney despite the fact ance with the accepted technique cern telephone wires from any great 265 hours and in the ten weeks determined from the landing weight that t11 ere was only 50 minutes of for the type, the point of touch­ daylight still remaining. The air­ distance. since he had taken up agricultural down cannot be determined in ad­ chart allows for an aircraft to cross At 1900 hours with only 31 flying he had flow n about 40 hours the threshold at 50 feet at 30 per minutes of daylight left the aircraft craft arrived over Lithgow 20 vance by the pilot with the degree minutes later and set off for on thal work, a ll of this time in of precision that will permit land­ cen t. above its power-off stalling reached a large town which the The accident to this aircraft came Katoomba with the pilot apparently the DH.82. ings on the end of the usable area speed and still pull-up with only pilot identified as Lithgow. Then as the culmination of a series of still intending to reach Bankstown to be attempted with safety. If a 60 per cent. of the runway used. he set off to find Katoomba 16 errors and omissions by the pilot. miles to the south-east, following a aerodrome. Not until the sun had The flight was badly planned, the road. Unfortunately, he selected the set did he commence to plan a land­ aircraft was poorly navigated and, wrong road and when he became ing in daylight, after realising the finally, the pilot failed to appreciate aware of this he returned to Lith­ impossibility of reaching Bankstown. the dangers of approaching dark­ At this stage he was over moun­ ness until there was insufficient time gow, reaching there with only 5 \ Procrastination zn a DH82 minutes of daylight left. A hurried tainous terrain and by the time he left to find and land on a suitable That Check for search for a suitable emergency I reached a more suitable area in the emergency landing area. When the vicinity of Lithgow there was in­ aircraft returned to Lithgow shortly An aero club pilot in New South from Griffith at 1645 hours and, landing ground resulted in an ap­ proach to a sports field, in the course sufficient time to properly plan and before it became dark an accident Water Needs Wales obtained his private licence although the pilot asked a bystander carry out a forced landing. late in 1956 and was soon under­ to phone the aircraft's departure of which the aircraft struck over­ of some degree had become almost taking long travel flights from time to the Wagga control centre, head telephone wires and a pole lin­ It is most llliely that the pilot's inevitable. Careful Thought Sydney to country and interstate he took no other steps to ensure that ing a suburban road. The aircraft centres. T he third of these travel his route, height or time interval fell onto a post and wire fence and flights, with a friend as passenger, would be known in the air traffic was substantially damaged, whilst A Bristol "Sycamore" helicopter, was to be via Cowra, Griffith and control centre. The aircraft had the pilot and passenger escaped with working under charter to a mining Deniliquin to Wagga, returning to been refuelled to full tanlls and it only minor injuries. company in Western Tasmania, left Sydney on the following day. They was the pilot's inten tion to proceed Queenstown one morning last departed Bankstown in a DH.82 at to Bankstown aerodrome via Yer­ Departing Griffith at 1645 hours, J anuary to carry out a camp shift 0920 hours but the passenger soon randerie (see diagram). En-route the aircraft would have had to Agricultural DH82 Strikes Fence in a survey area 40 miles to the became very airsick. At Griffith it he pinpointed himself at Temora maintain an average groundspeed of south. It had been refuelled to full was decided to return to Sydney and Young, which are both well 89 knots, without deviation from During Take-off tanks before departure and, when immediately without covering the re­ south of the desired track, and the the most direct route, to reach the task was completed late in the mainder of the intended route. next point recognised was the large Bankstown aerodrome by last light same morning, the aircraft set (viz. 1931 hours on this day) . This On 13Lh February, 1957, at about take-off was east at about three reservoir on the Lachlan river just knots, cons.tituting a tail wind. course back to Queenstown with The return flight was commenced would have required a tailwind 0910 hours a DH.82 taking-off from east of Cowra and ten miles north a field near Goulburn, New South the pilot and one passenger aboard. component of about 20 knots, The hopper was loaded with About half-way along the route Wales, on the first flight of a super­ whereas a sligh t headwind com­ 336 lb. of superphosphate and there and at a height of 2,000 feet the phosphate spreading operation fail­ DIAGRAM OF FLIGHT _pATH ponent was forecast for the route. was about 12 gallons of fuel on pilot decided to transfer fuel from ed to clear the boundary fence. T he It is appreciated that this return board. The resultant all-up-weight the auxiliary to the main tank pre­ fli ght was a departure from the aircraft was extensively damaged but the pilot was not' injured. of the DH.82 was approximately paratory to landing. Soon after the pilot's original intentions and, then 31 lb. in excess of the maximum of transfer pump was switched on, the again, the care of an airsick pas­ 1825 lb. permitted by the certificate main engine power failed and the senger can be quite a distraction. The fi eld was siluated in undulat­ of airworthiness. pilot had to carry out an auto­ These are, perhaps, mitigating cir­ ing terrain at an elevation of 2,000 rotation landing in rugged moun­ cumstances but it is apparent that feet above mean sea level. Only a The superphosphate loading point tainous country. He did this very the pilot gave very little thought to comparatively narrow section of the was sel up about 400 feet from the successfully but, unfortunately, the the planning of this stage of the field was suitable for take-off and eastern encl of the landing area and front wheel sank into marshy ground flight and his failure to submit flight landing and the maximum run avail­ it was from about abeam of this soon after touchdown and the heli­ details to the Wagga ATC centre able on this area was 1,583 feet. position that the take-off was com­ copter slowly tilted onto its port probably signifies more than just a The final 200 feet at the western menced. T he aircraft became air­ side damaging the rotors and the notification oversight. end of the take-off area sloped down borne and when the pilot realised rotor head. appreciably and the combination of he would not clear the fence he operated the hopper dump valve but The escape of both the pilot and LEGEND The pilot's navigation of the air­ this slope and electricity wires sus­ pended on 25 feet high poles across there was insufficient time to dis­ passenger from serious injury and craft, once the flight commenced, Intended Track SCA LE the eastern end dictated that take­ charge enough of the load to their subsequent rescue were vety was hardly better than his flight Probable Track 50 0 50 100 off be made into the west. The materially improve the climb per­ largely due to the pilot's skill and preparation. Apparently he follow­ Outbound Track -;AUTICAL MILES wind at the time of the attempted formance. I t was considered that resourcefulness both in the period -- -- ed the Cootamundra railway line for 19 18 not be necessary for the Depart­ of emergency and again after the accident. The responsible mam­ as ram water entering the tanks by between fuel and water. It seems in the container before draining and landing. In the very short period tenance engineer personally carried way of the ,·ents but the quantities most likely that he drained a full then checking visually for any line ment to prescribe in minute detail of time between power failure and out the refuelling from drums by of water involved rule these out. bottle of water from the auxiliary of demarcation which would be how these checks must be carried landing the pilot informed his base means of a hand pump from two Since the drum had been delivered tank and this visual Lest procedure created by the presence of water; out; it is the responsibility of every of the emergency, its probable separate drums, each of which had to the operator only seven days or by checking the drainage samples individual concerned to ensw·e that cause and the position of the air­ was inadequate to detect such an been sampled for water by using a prior to the accident it is improbable he follows carefully a procedure craft. pipette and a one-pint glass milk that the accumulation of such a event. His failure to detect the by chemical means such as water bottle. When the main tank became quantity of water was related to water by its appearance, feel or detecting paste or paper. It should which has no loop holes. After the landing he again used the full, about seven gallons remained the fuel storage conditions at smell is, perhaps, surprising con­ radio to report the condition of the in the first drum. This was put Queenstown, particularly as the sidering his experience, but these into the auxiliary tank and then bungs were sealed and secure with aircraft and occupants and to co­ sensory tests are not always re­ ordinate the rescue operation. A a second drum was opened and, no sigr:is of leakage. ground rescue party reached the after testing, the auxiliary tank was liable. In this case the check of the helicopter 29 hours later, after filled by adding another 17 gallons. V\fhatever may have been the auxiliary tank was made whilst he traversing some very rough country One pint of fuel was then drained origin of this water and however it was lying on his back under the Agricultural DH82 Collides With on foot. An R.A.N. helicopter was separately from each of the two may have got into the drum or into· aircraft on wet ground. Rain was main tank drain cocks into the used to lift out the rescued and the the aircraft tanks, it remained un­ falling and, in addition, the glass rescuers on the following day and same bottle as had been used for detected despite the carrying out of Electricity Wires to fly in equipment and personnel the drum sampling checks. After the normal water contamination of the bottle had the not unusual for the repair work. Eight days each drain, the engineer visually in­ checks before flight. There is no green colouration. He carried out after the accident the aircraft was spected the contents of the bottle evidence that the engineer con­ the refuelling and the tank drain A DH.82 engaged on a pesticide sion wires. The Company operat­ ing the aircraft required its pilots flown out under its own power. and, having satisfied himself that cerned carried out his checks care­ checks without assistance. dusting run over a field of potatoes no water was present, disposed of lessly and the procedure he follow­ near Gatton, Queensland, on 25th to inspect the area of proposed low level operations before commenc­ When the aircraft was lifted back the contents. Lying on his back ed was one commonly used and February, 1957, collided with ing flying and record the nature and onto its undercarriage a complete under the aircraft, he then un­ approved within the operator's The most careful attention to electricity transmission wires at disposition of obstructions on a examination of the fuel system was fastened a cover plate in the under organisatintercd the induction section of the of an inch of water in the bottom possible that it consisted wholly of before the first flight on any day arrricultural pilot after which he broke out in the engine area but, engi ne. The aircraft auxiliary tank of the drum and this level would water : if the sample was not so a.nd after each refuelling, but the ~~s certified by his employer as a fortunately for the unconscious pilot, was used during the day prior to carefully drawn then water may be equivalent to about three pints. methods of detecting water in fuel competent agricultural. pi.lo~. · !he a rescuer was able to keep it under the accident, and so it is apparent The amount of water originally in have been lost during withdrawal accident occurred durmg his sixth were not prescribed. Since this control long enough by throwing that the water causing the power the drum could not be determined. and only fuel retained. In either hcui: of operations following certi­ earth on it for others to pull him failure was introduced into this but it was not less than seven case. no line of demarcation would accident the Department has re­ ticalion. clear. tank during the last refuelling be ~vi.dent despite the presence of pints (i.e., the amount recO\·ered) vised Air Navigation Order 20.2.5 I t was determined · th.at this operation. and could have been more con­ water in the fu el drum. The field being dusted had a row and it now suggests two satisfactory of 30 feet high wooden poles spaced accidenl was caused by the pilot sidering the loss of liquid from the but alternative methods of detecting misjudging the point at which to It was established that the last aircraft tanks whilst it was lying on In the drain check of the air­ aboul 150 feet apart along the water in the tank drain samples. viz., eastern boundary on which were commence pull-up to clear the Tefuelling was carried out before its side. Other possible sources of craft tanks, the engineer again wires. the first flight on the day of the the water have been suggested such looked for a line of demarcation by placing a quantity of known fuel suspended four electricity transmis-

20 21 cently comm enced flying with the east with a downwind component. action. The undercarriage struck approximately 50 feet abO\·e terrain Fatal Accident 1n Authorized club, was aware of its existence. Apparently, the strip was in a shal­ the cables causing the aircraft to with the aircraft in the "pre­ T he accident again demonstrates low valley and, as the aircraft nose into the ground after tra\·elling cautionary" attitude. The cause of the need for the highest degree of descended on a long straight-in a further 150 feet. After bouncing the accident was assessed as the Low Flying vigilance when low flying, and it approach, it was maintaining almost 18 feet it came to rest standing in pilot"s failure to exercise the degree should be well noted that an area a constant heigh t above the ground a vertical attitude 530 feet sontli of care d<'manded by the circum­ designated and approved as a low over which it was flying. The pilot of the la nding strip. stance~. On 24th February, 1957, at 0945 almost indiscernible against the flying area carries no guarantee stated that it was not until he was hours a DH.82 aircraft flew into hackground of grass and trees. that the area is free of obstructions ,·c1y low that he realised he was On a normal approach from the ln lookiug for an explanation for high tension power cables, crashed which can be hazardous if ignored. und<·rshooting, the position of the ~outh. the poles and the gap cul the pilot operating as he did, his and burnt, whilst engaged on low Apparently this high tension line It also highlights the necessity for aircraft a t this time being about one in the trees to take the cables log- hook was examined and it was flying in an authorised low flying had been erected subsequent to the training organisations to prominently mile from the strip 50 feet above would be clearly \'isible, but when discovered that he had logged 408 area. ·fhe aircraft struck the approval of the area as a low flying display an up-to-date large scale terra in. approaching at a low altitude the homs 50 minutes in the 90 days area and, although its existence was cables whilst in level flight about map of the training areas with all poles would be camouflaged by preceding the accident. Although it 33 feet above ground level. It then generally known by club me~bers, trees and the gap would not be is impossible to say to what extent obstructions, including power lines, About this time he noticed that struck the ground in a near vertical it is not known whether this parti­ the other DH.82 was about to apparent. In addition to this, the fatig11c contributed to this accident, attitude, overturned, and was de­ cular instructor, who had only · re- clearly marked on it. touch down on the strip but in the approach was being made into the it was certainly a factor of some stroyed by fire. Both pilots were opposite direction and this surprised sun. significance. killed on impact. There was no him as he was not expecting the evidence of any pre-crash defects or other pilot to return until two It would appear that there was A point to remember is that malfunclioning which may have hours later. He stated that he then no question of the pilot having mis­ fatigue is not just a matter of being contributed to the accident. elected to continue the approach at judged his height above the cables. tired. Quite often it is a state of a reduced airspeed in a nose-up H e elected to land with a down­ mind and body, probably induced The aircraft, which was owned Agricultural DH82 Collides With attitude with sufficient power to wind component of ten knots on a O\·er a long period, which results in by the Gilgandra Aero Club, New maintain level flight, thereby gain­ strip with an effective operational mental and physical perfo1mance ing time for the other aircraft to llluch below normal. Perhaps the South Wales, departed from the local length of only 1,320 feet, as well aerodrome at 0930 hours being High Tension Power Cables clear the strip. During this stage of most insidious thing about fatigue as making the approach into the flown by an instructor and a private the approach he saw the cables im­ is that quite often the symptoms pilot who was in the process of ob­ mediately in front of the aircraft sun, and flyi ng the last mile of the go unrecognised by the person taining a DH.82 endorsement. The At approximately 0845 hours on all landings except when the air­ but too late to take any avoiding landing approach at a height of concerned. purpose of the flight was to prac­ 22nd May, 1957, an agricultural craft first arrived, were made to tice forced-landings and low flying. DH.82 flew into high tension power the south, thereby avoiding the The aircraft was flown to the cables and crashed, when approach­ approach over the cables. authorised training area where it ing to land on " Gidleigh" Station was observed performing a practice strip near Bungendore, New South Shortly after arriving at the strip forced-landing. from which a baulk­ Wales, at the completion of a ferry operations were commenced and ed approach was executed. The flight. The pilot received minor continued throughout the following aircraft then proceeded in a north­ injuries to his face and the aircraft day. On the next two days the ------, westerly direction flying close to the was substantially damaged. weather was unsuitable for the CORRECTION ground. About ten minutes later dropping of superphosphate and no the aircraft was obsen·ed in the Six days prior to the accident this work was done. On the morning of Aviation Safety Digest No. l 0 conta ined an account of a same area proceeding in a southerly and another pilot had proceeded to the fifth day operations were recom­ DH.82 w hich beca me lost on l 0th November, 1956, duri ng a direction flying at tree-top level. It "Gidlcigh" in separate aircraft for menced but were abandoned about flight from Jamestown to Waikerie, South A ustralia. A forced was flying over cleared land when the purpose of spreading super­ mid-day due to high winds. The landing w as carried out and the position of landing which it was observed to suddenly dive phosphate. Both pilots stated that pilot concerned in this accident then read " l 50 miles west of Jamestown a nd 122 miles northwest into the ground. on arrival over the prepared strip flew about 14 miles to his working of Waikerie" should have read "l 50 miles ea st of Jamestown two complete circuits were flown base at Queanbeyan- a normal pro­ a nd 122 miles northeast of Waikerie" . The aircraft had flown into the and a number of cables observed, cedure on completion of the day's centre of the span of two steel high particularly a line of poles and flying. The other pilot flew to tension cables carrying 11,000 volts. cables to the south of the strip. On Goulburn, his home town, intend­ The cables were suspended between this occasion both aircraft were ing to return to "Gidleigh" the fol­ two 35 feet high poles which were landed to the north over the cables. lowing mornin"g. approximately 300 feet apart with After landing both pilots walked the area between the poles quite along the strip and discussed these On the sixth morning the pilot clear of trees or scrub. Although high tension cables which were departed Queanbeyan about 0830 the counh-y was fairly open the two 25 - 30 feet high and 700 feet from hours and flew to "Gidleigh'', fly­ supporting poles would have been the south end of the landing strip. ing at 1,000 feet. Although he obscw·ed by trees when approach­ It was agreed that all take-offs noticed there was a southwesterly ing from the direction flown by the would be made to the north away wind of about ten knots, he decided aircraft. Also, the cables were a from the cables. I t also transpired to carry out a straight-in approach light grey colour and probably that until the time of the accident on the strip landing into the north-

22 23 The captain's bel ief that he It is clear from the evidence that the primary winding, and was the sole effect of the test set. AIP-RAC/ 1-4-1, paragraph 1.2, should have been advised of the this incident arose simply through stales th at "aircraft (operating in a movement of the DC.4 was in the captain of the DC.3 effecting This accident illustrates the ][ N (c ][ lD> lE N 1r § control area) shall commence a error. The circumstances under the change of level far slower than danger associated with the use of change of level immediately on re­ which traffic information will be that specified in AIP-RAC/ 1-4-l. a magneto timing or synchronising passed to aircraft in a control area ceipt of instructions unless a later Action Taken device which will allow a sufficient­ time is approved by A.T.C." and are specified in AIP-RAC/1-4-3. ly rapid collapse of the pl"imary cur­ "aircraft" shall effect changes of Briefly, these are when t~e. separ~­ Because of the seriousness of this rent when the points open, to pro­ It Would Have Been Much Closer In Cloud level at the rate of 500 feet per tion falls below the mm1ma, m incident and the possibility that duce a spark at the plugs and thus minute unless otherwise approved V.F.R. conditions when separation there were other pilots who did not possibly result in an inadvertent by A.T.C.'" The descent clearance is not provided between departing fully appreciate the significance of engine start. Apparently a number At 2108 hours E.S.T. on 26th September, 1957, a DC.4 issued to the DC.3 did not specify aircraft and arriving aircraft, and the change of level requirements, of maintenance engineers believe and a DC.3 arrived over Nhill in the Melbourne Control a later time for the descent to be when requested by the pilot. T he Operations Letter ATC . ~20 was that the magneto is earthed (i.e. issued a few days after this occur­ Area flying on opposing tracks and at the same altitude. commenced and no variation from captain of the DC.3 did not request the primary winding) once the traffic information and the other ence. There is an important mes­ The ~rews were unaware of each other's position until the the prescribed rate of descent was leads from a synchroniser test set are approved. As mentioned earlier, conditions for passing traffic infor­ sage in this letter and its contents connected lo the magneto in lieu of aircraft were dangrously close when each captain sighted thl' clearance was passed to the • mation to the aircraft did not apply . should be well digested . the normal switch leads. This is the other's navigation lights. Both took abrupt evasive oc. :1 at 2050 hours and the esti­ incorrect. The majority of test action to avoid a collision. mated rime of passing was 2109 sets do not earth the magneto but hours; thus, the descent to Aight apply a relatively high resistance The Circumstances on "west bound" traffic and was level 70 should have been completed across the primary winding. This advised that a DC.3 was due over by 2054 hours, 15 minutes before provides a certain amount of The DC.4 departed Adelaide for Nhill at 2108 how-s at flight level the estimated time the aircraft damping but it will not necessarily Melbourne *2016 how-s, cleared to 70. The DC.3 promptly called and would pass. A Lively Spark prevent the magneto from produc­ cruise at flight level 80. T his air­ said "that is not right. I was ing a spark of suffi cient intensity to start an engine. craft reported over Ta~lem Bend, cleared further back to descend to The captain and first officer of During a fligh t in a Dove it was T he aircraft, being chocked at the last reporting point before flight level 70 but was not advised the DC.3 state that the descent was found that the starboard engine the nosewheel only, moved forward, I t should be remembered that entering the Melbourne Control of any east bound traffic". At the commenced immediately on receipt was running roughly when the jumped the chock, and careered out Area, at 2034 hours fligh l level 80, whenever the switch lead is re­ Li.me of lhe incident the weather of the clearance. As the clearance right-hand magneto was selected. of the open hangar. In so doing moved from a magneto installed on estimating Nhill 2110 hours. The was fine and the aircraft were flying was received at 2050 how-s and the After a ground test which con­ the port wing contacted the edge of an engine, precautions must be aircraft passed this position. to bt'low broken cloud. aircraft was only at flight level 80 firmed this report, the aircraft was the door, and this, combined with taken to prevent an inadvertent Adelaide A.T.C. who relayed 1t to by 2108 hours, it is evident that the pushed just inside a hangar, nose the thrust from the starboard engine start. Particular care is Melbow-ne A.T.C. al 2037 hours. average rate of descent was in the outwards, and chocked at the nose­ engine, caused the aircraft to swing necessary with magnetos having an Analysis order of 56 feel per minute. The wheel only. The throttle was left to the left. T he starboard wing impulse starter as only a slight The D.C.3 departed Melbourne captain readily admits that he in the full open position and the passed over a low fence, brushed movement of the engine crankshaft for Adelaide 1946 hours, cleared lo The sc-paration standards applic­ adopted a slow rate of descent. He fuel was left selected ON. T he the tops of some parked cars, and is required to trip the pawls of a cruise flight level 90. At 2047 hours able to aircraft operatinR in con­ has stated that, when he asked the defective magnefo was removed and the aircraft finally slopped with the "wound" starter and thus allow it reported over ~ube~k 204~ how-s. trol areas arc specified in ATP­ first officer to request permission to the replacement magneto - which port wing jammed against the the magneto armature to flick over flight level 90, est1matmg N~ul~ 2108 RAC/ 1-4-4. Paragraph 8.1.2.2.2 of descend to fli ght level 70, it was his was fitted with an impulse starter corner of the hangar with the star­ and produce a very healthy s~ark. hours. and requested perm1ss1on t.o that section stales that for aircraft desire to make a slow descent but - was offered up to the engine board engine still running. The Any one of the following precau­ descend to flight level 70. This on the same track in the opposite apparently omitted to instruct the coupling. I t was not seem ed but engine was finally stopped by clos­ tions will ensure that an inadvertent message was passed to Melbourn<' direction "vertical separation will first officer to request approval to was held by an engineer. The ing the throttle and short circuit­ start will not occur. A.T.C. through Nhill Aeradiot. At be applied for at least ten minutes depart from the prescribed rate. magneto switch leads had been dis­ ing the operating magneto. The 2049 hours. Melbourne A.T.C. ad­ before and after the aircraft are The captain made it clear that, connected from both magnetos for accident resulted in four mainten­ (a) disconnect the prima ry wind­ vised Nhill Aeraclio that this air­ estimated to pass or are estimated to whilst he was aware that he had the subsequent timing adjustments ance engineers being injured, fairly ing from the contact breaker craft was cleared to descend to have passed". The minimum verti­ no approval to descend at a slo.w and a magneto synchronising test extensive damage to the aircraft, points, flight level 70. Nhill aer.adio passed cal separation specified in a control rate he believed it would be m set consisting of lamps and a buzzer and damage to fencing, the hangar, area up to 19,000 feet is 1,000 feet this message to the aircraft and ord~r to do so because he had re­ was connected to each magneto. and two private cars. (b ) remove the distributor cover, received an acknowledgment. At (J\IP-RAC/1-4-6, paragraph 8.2 J. ceived no advice of conflicting The high tension lead from the dis­ 2053 how-s, Nhill Aeradio advised From the E.T.A.'s of the aircraft at traffic. tributor was also connected to lhe After the accident the magneto Adelaide A.T.C. of the amended NhilL the estimated time of passing in question was connected to the ( c) disconnect the high tension replacement magneto. During the leads from the plugs, fli l!;ht level and estimat~d ~ im e of was 2109 hours and consequently action of synchronising the mag­ same test and intermittent sparking a rrival over Nhill of this aircraft. th e- DC.3 had to be at flight level netos the propeller was turned, this was obtained whilst turning the * Nhill Aeradio exists to relay messages ( d) earth the magneto prima1y 70 by 2059 hours for the standard between aircraft and Adelaide A.T.C. caused the impulse mechanism on impulse starter by hand. The in­ At 2108 hours, the captains of separation to be maintained. F ro1~1 centres when the aircraft cannot com­ the right-hand magneto to operate tensity of the spark was similar to winding at the magneto. the DC.4 and the DC.3, when in the recording of the Melbourne Air municate direct with these places. and the engine to start. The right- that which could be expected from T raffic Control communications for an impulse starter magneto with the vicinity of Nhill, sighted. each t T he direct track from Melbourne to hand magneto came adrift, being the relevant time, the Nhill Aeradio slightly dirty contact points, or a Note: In some types of magneto other's navigation lights, switched Aclt>laide is inside a control area and :etaincd in the hand of the on their landing ligh ts to alert the log and the testimony of the crew the division of responsibility between weak coil or condenser. This lower this is accomplished automatically mgincer, and the engine continued other and simultaneously took of the DC.3 it has been established Melbourne and Adelaide A.T.C. cen- efficiency was due to the loading or when the switch lead connector abrupt evasive action to avoid a that the DC.3 received the clear­ 1 res occurs at the South Australian· l nm on the left-hand magneto. damping effects of the test set on is removed. collision. The DC.4 promptly ask­ ance to descend from flight level 90 Victoria border, 37 miles on the ed Nhill Aeradio for information to flight level 70 at 2050 hours. Ade l a ide~ side of Nhill. 25

24 Remember that a magneto will a ircraft) may result in a Ji,·e mag­ jnspections to be performed at be " alive'' if the magneto switch neto. And last, but not least, as initial installation, after 100 hours Some seven minutes after setting from clouds arc muumum hibit V.F.R. fligh t under course and when at an altitude of lead is broken or has a high resist­ this incident demonstrates quite flying time and thereafter at inter­ conditions and allowing a such conditions, the chances approximately 4,500 feet, the DC.6 greater margin in certain in­ of sighting other aircraft are ance connection. Similarly, a poor adequately. a magneto is not neces­ vals not exceeding 50 hours flying contact in the magneto switch or time. It is considered that if these passed 50 FEET below the DC.3 stances reflects good judg­ greatly reduced and it is in the earth return path from the sarily rend<'rcd inactin' when a inspections are performed as re­ The crew of the DC.6 did not see ment. This applies parti­ preferable to fly under I.F.R. switch to the magneto (often sync hronist>r set is attached in lieu quired there is li ttle danger of a the DC.3 at any stage. cularly to the V.F.R. depar­ through the bonding system of the of the sw i lch leads. complete cable failure occurring be­ ture which, although initiat­ (d ) Note carefully the disposi­ fore broken wires or strands are dis­ The weather was fine with a ed by ATC, will be immediat­ tion of aircraft advised as covered. This is borne out by the slight haze and 2/8ths to 3 / 8ths ly cancelled if some factor essential traffic by A.T.C., · iact that this is the first complete cloud at 16,000 feet. However, on affecting the ability of the and if possible obtain a failure of an Auster rudder cable the 247° diversion, both aircraft pil•Jt to fly V.F.R. is advised sighting. Passing information for quite a long time. were heading directly into the sun. to the controlicr. on other aircraft which arr Rudder Control Cable Failure The pilots later reported that their operating in proximity lo abil ity to sel' another aircraft al1ead ( b) When approaching the de­ If you should experience a rudder scent position, give careful you will enable the con­ cable failure in flight, directional was considerably reduced by sun­ troller to relay this informa­ During a period of dual instruc­ as shown by the general brittleness g-lare. This was evidently the consideration to whether stability will depend on the engine V.F.R. flight can be main­ tion to the aircraft concerned. tion on circuits and landings in an of the wires in this area, the brittle­ power being used at the time, the reason why the crew of the DC.6 If you are in doubt concern­ Auster Jl, the port side rudder con­ ness diminishing with distance from did not sec the DC.3. tained to the destination, be­ direction of engine torque relative fore electing to proceed ing the relative position of trol cable broke whilst the aircraft the break. Although the amount of to the broken cable, and/or the V.F.R. In marginal con­ another aircraft advise A.T.C. was on final approach. The cable grease presenl on the cable had pre­ Following this incident Head airspeed. Directional stability can ditions it is advisable to accordingly. failed at a point about one foot ,·entcd any wire failures from tarnish­ Office Operations Letter ATC.207, be achieved by setting cruising obtain an aerodrome weather from the rudder pedals where it ing "·ith age there is no doubt that 25th June, 1957, was issued sum­ power, assuming a laterally level report before making this ( e ) If for any other reason, you passed under the change of direc­ the failure was progressive and marizing the rules applicable to attitude and by allowing the rudder decision. In certain con­ doubt your ability to main­ tion pulley, immediately beneath many wi re breaks were present for V.F.R . flight in control areas with to streamline. The Auster rudder ditions whether a flight can tain adequate separation the cockpit floor. The landing was some period before the complete advice to air Lraffic controllers and control system consists of two in, be completed under V .F.R. with other aircraft, whether effected without damage to th1' air­ failure of the cable occurred. I t pilots on points to be observed on dependent cables operated from in­ is strictly a matter of judg­ temporarily or for the whole craft. seems probable that the strands had such flights. The suggestions to dependent pedals. Attached to each ment but the choice to re­ manoeuvre, the safe cow·se not unravelled sufficiently for the pilots in that letter are reprinted pedal is a light spring which applies main l.F.R. in doubtful would be to request alter­ wiff brt>aks to have been obscJYcd below Lo emphasize their import­ The cable was of 7 x i construc­ approximately four pound tension cases reflects good judgment. native instructions from tion, that is seven wires per strand, in the normal course of an inspec­ to the cables. In the event of a ance. A.T.C. seven strands per cable; the star­ tion, a lthough they probably would cable failure the spring tension on ( c ) If forward visibility is re­ ha\'(' bPl'n discovered if the cable board cable of similar construction the remaining cable may be suf­ "(a ) Use reasonable restraint 111 duced due to the position of ( f) Be alert a t all times especially had brl'n cleaned down and a cloth was found lo be fully serviceable ficent to apply a small amount of adopting the V.F.R. pro­ the sun or during precipita­ when the weather is good - with no strands broken. As the air­ nm over the cable to pick up any rudder, but this can be overcome cedure if doubt exists as to tion, advise A.T.C., to obtain U nlimitep visibility may broken wire ends which otherwise craft log book covered 960 hours of by pulling the rudder pedal to­ your ability to remain V.F.R. alternative instructions. Al­ encourage a sense of security would not he readily \'isiblc. operation and no entries had been wards you \.vith your toe, thereby Visibility and distance though the rules do not pro- not at all justified." made referring to replacement of permitting the rudder to streamline. control cables, it is probable that The history of Auster rudder With care the aircraft can then be these cables had been in use during cable failure; indicates that the manoeu\Ted to a landing usmg the whole of that period. The air­ majority have occurred in the cle,·ator and aileron controls. craft had flown 16 hours since the ,·icinity of the pulleys. Many pro­ previous 50 hourly inspection and. posals for increasing the life of the during this period, the daily in­ rudder cables have been tested. spections had been performed by a These have included modifying the .:::-inmercial pilot holding a certi­ circuit to a "closed-loop" system. the ficate of maintenance apprm·al. introduction of larger diameter pulleys. and the binding of the Too Close Under microscopic examination cable in the pulley area with cord. many of the wires exhibited fatigue These schemes have nol resulted in tailurc whilst others exhibited neck­ any appreciable improvement and At L608 hours on 22nd April, .. ' ./ ing; a characteristic of tension it is now considered that short of 1957, a DC.3 set course on the 247 ° failures. The wires of many strands redesigning the entire rudder con­ diversion from Sydney Airport for '1.ad made elliptic impressions on trol system. the problem will not be Wagga cleared to climb V.F.R. to the surface of adjacent wires in­ easy to solve. In the meantime Right level 60. One minute later / dicating local overloading and a meticulous periodic inspccti0ns lo a DC.6 set course for Melbourne on proportion of wire failures in the locate any damage to the cable rhe same diversion, cleared to strands. before complete failure occurs are .:limb V.F.R. to flight level 120. essential. S•.ich inspections are The aircraft were advised of each The cable was work-hardened in called up in Air Navigation Orde:·s, other's movem ents. There was no the immediate vicinity of the break Section 105.1.3.0.2.6. Issue 2, the other significant traffic.

26 21 DESIGN NOTES SURFACE CONTROLS Stabilizer Actuator

Wrong Screw Fouled Stabilizer Actuator Control

ST AB/LIZER BEAM FIRE DESTROYED a jet fighter shortly after it was ~ \ seen to go into a steep dive from level fligh t and crash. The pilot was killed. An identical type aircraft which experienced stick­ ) ing controls led to a thorough examination of the tail sw-face control svstem. Probable cause of the fatal accident was fou~d to be a misplaced machine screw in a fairing attachment strip. The fairing was attach­ ed by seven screws; one was required to be shorter than the others to avoid interference with movement of a lever in the control system. The reason for the sticking controls was that a longer screw had been installed in the critical location. This may have occmTed on the aircraft involved in the fatal accident. • • HOR. ST AB I LIZER • .s 0 Sole precaution against using • '1:1' 0 -u a screw longer than the one 0 ~ which would clear the lever -0 ..e Q) .... was a notice on the fuselage: ~ 2 "USE A SHORT SCREW ONLY", and an arrow ..f? .s 0 QI pointing to the critical fastene·r hole. Since the clear­ c: -:E 0 ance margin was a mere .040 inch when using the O> .... c: Q) correct length screw, the question as to what com­ Q) O> prised "a short screw" was not readily apparent to - c: ~ 0 a mechanic, especially were he working under adverse ~I circumstances. Consequently, the inevitable substitu­ ~ e tion of the wrong screw occurred. t; § QI .... VERT ICAL :: 0 STABILIZER Uu0 Q) Procedures for adequate maintenance and operating practices established by the designer should be consistent with average human effort, ability and attitude.

Ref: Davis. RC, Group Captain, Dir. of Flight Safety, R.C.A.F. "AIRCRAFT ACCIDENT INVESTIGA­ GATION" . IAS Reprint No. 575. ( By courles;• Flight Safety Foundation /11corporated)