COMMONWEAL TH OF AUSTRALIA

DEPARTMENT OF CIVIL AVIATION

I DIG EST No. 5

FEBRUARY, 1956

Prepared by the Division of Published by Authority Accident Investigation and Analysis of the Director-General P l lHTCD BY Hf:OGCS a BELL Pn. LTD . , MARY80 ROUGH, V ICTORIA CONTENTS

Page PART I-AVIATION NEWS AND VIEWS Crewmanship - A Veteran Pilot's Views 3 Planning a Travel Flight in a Light 5 Surface Conditions at Outback Aerodromes 6

PART II -OVERSEAS ACCIDENTS Super Constellation Inadvertently Ditches in Shannon River, I re land ...... 7 Fuel Exhaustion in DC.3. Near. Pittsburgh, U.S.A. 1O Emergency Landing in Convair as Result of Failure ...... 11

PART Ill -AUSTRALIAN ACCIDENTS DC.3 at Sydney, N.S.W . - Undercarriage Collapse 14 M id-air Collision at Wagga, N.S.W. 16 Norseman - Undershot and Overturned 17 Fatal in DH.84 Dragon ...... 18 Aerial Ambulance A ircraft Ditched in Sea ...... 19 Take-off Accident - Moth Minor 21 Norseman Encounters Soft Patch on New Guinea Strip and Overturns ...... 21 DH .83 Fox Moth - Caught in Subsidence in Lee of Mountain Ra nge, New Guinea ...... 22 Fatal Spin in DH .82 ...... 23 DH.82 - Unauthorised Low Flying 23 DH.82 Hits Tree Whilst Flying in Cloud ...... 24 Wackett Trainer - Fatal Stall During Low Flying 25 DH.82 Strikes Tree on Approach at Maylands, Western Australia ...... 25 Wacket Trainer - Major Structural Failure in the Air 25

PART IV- INCIDENT REPORTS Door Warnings in Pressurized Aircraft ...... 28 Unsafe Separation on Controlled Air Route 29 Low Visibi lity Approaches at Nandi, Fiji 29 A new Twist to the Overspeeding Propeller 30 Incident Report Leads Directly to Changes in Operational Control Procedures 31 ---- ,,,,--

PART I AVIATION NEWS AND VIEWS

Crewmanship - A Veteran Pilot's Views (Because of its general interest the fol,­ lowing article is reproduced from Pilo1t's Safety Exchange Bulletin 54-109, issued by the Flight Safety Foundation, New York, U.S.A.)

OT long ago I visited the scene of they are the captains who scream and a major air accident. The positions shout at co-pilots, or maybe don't allow Nof the radio receivers and the head­ the co-pilot to do even the most menial ing on which the aircraft struck indicated chores. that some confusion as to the proper approach procedures had contributed to the "Let's . put a new, eager co-pilot on a accident. trip with Captain Doe. He's heard of Doe's reputation and he's deeply concerned. He "Since about half of my ten thousand wants to keep his job badly; and to do so, he - hours has been spent as co-pilot and half knows he must not aggravate Captain Doe. as captain, I tried to visualize what went on in the cockpit just prior to the crash. "So on the trip, Captain Doe shoots an My assumptions are based upon the hundred approach at an airport, using his own short or so captains I have co-piloted for and an cut - BUT SAFE - procedure. His co­ equal number of co-pilots I have had with pilot has his manual opened and notices me. the procedure being flown isn't what the book shows. Very cautiously he reports this "In the first place, it was definitely deter­ fact to Captain Doe. mined that the captain was flying the ship at the time of the accident. In most "Listen, you, Captain Doe screams, accidents I have been familiar with, the 'You're just a new idiot. You sit there and captain was at the controls at the time of keep your eyes open and your mouth shut. the crash. In this case, the co-pilot either I've been flying since you were born; you did not see the error or else he saw it and just watch and keep your mouth shut'. Or remained silent. some such strangely worded phrase. "Incredible, you say? A co-pilot saw an "We all know one or two such characters; accident coming and didn't say anything? I even get a laugh out of their briskness. Let's create an imaginary accident and see But to a co-pilot anxious to please, it isn't if this is possible. a bit funny. He promises himself to keep his mouth shut from now on. All co-pilots say they will speak up at the last minute "Iron-Butt" Captains to avoid an accident, but who can define "Captain Doe is a very fine pilot - one the start of that last minute? of the best. Among the other captains he "So several approaches later, Captain rates the tops in respect to his knowledge, Doe makes a mistake. He shoots the pro­ ability and judgment. The co-pilots all cedure turn on the wrong side of the leg. agree to these fine pilot characteristics, but A stupid mistake, you say. There must they also add that he's an 'iron butt'. Every be a means of conteracting mistakes to has several of these 'iron butts'; avoid trouble.

3 "The co-pilot sees the error of the incor­ this, as it is he alone who makes the final Planning A Travel Flight In A Light Aircraft rect turn, but he remembers the earlier decision. incident and tells himself that Captain Doe "Every co-pilot at the controls is under (During 1954 Dr. J. N. Haldeman and his wife made a private touris-t flight from is using some other unorthodox procedure. the direct and positive supervision of his South Af1·ica to Australia. Before setting out they circulated a lette'r to interested There is no warning time left; the last captain. Very few captains will sit and organizations which is reproduced below. The value of the information it contains, to possible chance to rectify the error has been watch a co-pilot overshoot a runway, etc., such organizations as and the way in which it would facilitate the removed. The ship and all its passengers flight and any search and rescue action will be readily app1·eciated. This example are lost. without instructing the co-pilot in corrective measures. . could with advantage be copied by 01ther pilots of light aircraft on international "The underlying cause of this accident flights to or from Australia or even by ligmt-plane pilots on extended travel flights "On the other hand, a captain's only within Austmlia.) is poor crewmanship. The fact the crew active supervision comes once a year on a did not function as a crew, but as separate line check ride and twice a year under a individuals, caused this accident. six months' check. Any bad habits which a OR those who did not receive our be found is on a road, beach, field or any "Possible, but not probable, you say. In captain might have developed may be dis­ first circular, I, Dr. J. N. Haldeman, open ground. We usually try to fly within recent yea1·s some of the ail'lines may have guised on this periodic check. Thus we FPilot, and Mrs. Wyn Haldeman, gliding, or at least walking distance (20 inadvertently urged these very unhealthy have a co-pilot, when he flies, having expert crew, are planning a private tourist flight miles) of roads, railroads, rivers or coasts. to Australia in "Winnie", red Bellanca conditions, building a wall between captain advice and guidance. The captain, on the " 'Winnie' has retractable undercart. The and co-pilot, so that the co-pilot rarely-flew. other hand, is practically alone when he is Cruisaire, ZS-DEN. We will be writing stories on our trip. Our plane has a 150 h.p. next probable place is that we may have Although I'm sure the company did not flying. It is easy to see why the captain is landed in swamp or water. Our plane is desire it, their co-pilots became mere 'push generally flying at the time of the accident. Franklin engine, gross weight 2,150 lb.; cruising speed 140 miles per hour. In this a low wing monoplane, with reinforced buttons' for the captains. cabin. In case we had to stall it in on some Voluntary Correction aircraft we have travelled across sixty "This Is Not Crewmanship ! countries and territories in North America, bush there is a good chance of walking out "The only possible way to correct this Africa and Europe. We are Canadian citi­ without serious injury. If we should land "Since World War II there has been a situation is for the captains themselves zens, resident in South Africa. Our pass­ in water, the wooden wings with air pockets vast amount of experience in the right seat (not by regulation, which would destroy ports are good for "All Countries". We have will keep the plane afloat, but in addition -often as much or more than in the left. the harmony or crewmanship) to allow the smallpox, yellow fever, cholera and typhoid we have an air mattress which we use to Some captains have treated co-pilot's almost co-pilot to question any act he does. Any international certificates; area club customs sleep on, that will support six hundred as equals. In pre-war days, when captains co-pilot who abuses this privilege should be carnet; Shell and Vacuum fuel carnets. We pounds. This will further aid in keeping had all the experience and co-pilots were disciplined on the ground. will be carrying no freight, cargo or pas­ ourselves and plane afloat. We have Mae still students, this was an unheard-of sengers, only personal effects and emer­ Wests and shark repellent. We have had situation. Today the very low accident rate "One other consideration on this subject gency equipment and supplies. We will re­ experience in rugged country and have in face of very complex equipment shows of crewmanship which is extremely difficult quire 80 octane petrol although, if neces­ studied everything from the "Bombard that the World War II co-pilots are valuable to explore is that of the few dangerous sary, higher octane can be .used. Story" to "Survival" issued by the Depart­ assets in the right seat. captains. I believe these 'accident prone' ment of the Air Force, . This pilots are few and far indeed. The very few "Wyn and I have reduced our weight is the best information we have found. We I've known are all dead and no longer a thirty pounds each to allow an additional carry food, two gallons of water, a Cole­ Use All T olents problem. sixty pounds emergency supplies and fuel. man G.I. camp stove, air mattress and This was an unhappy but worthwhile blankets. When we wish to make a dawn "In my opinion an airline crew should "In summary, I personally believe that effort. take-off we like to sleep in or beside our utilize to the maximum, all the available the should check and train, if airplane. experience in the crew. True, there must necessary, in crewmanship. Re-educate the "Search and Rescue.-To assist 'Search be a chief, and this must be the captain. procedures of their 'iron-butt' captains; and and Rescue' en-route, please take note of "Radio.-As we have received no informa­ But when two possible courses of action use the total experience of all crew mem­ the following information. We have one tion that radio is compulsory on this route are open for consideration, he should utilize bers on the flight. They pay considerable thousand mile range if we fill our spare we have removed our radio as we have all the talent he can for his decision. He is money for the experience in the rig·ht seat; tank. We fly strictly contact. We have found on previous trips it is not worth the not relinquishing his authority by doing don't throw it out the window." never required overdue action and it is un­ weight and drag. Equipment to meet the likely that it will be required on this trip, varying radio requirements en-route is too but just in case- our plane is vermillion heavy and expensive to use in a light plane . . red, which is the easiest colour to see, but VHF has such short range that it is only we realize that a light plane is very dif­ useful for aircraft control. We have found ficult to find so we are prepared to survive that radio for airport control is unnecessary indefinitely at any point en-route. If we do at familiar aerodromes, but complicates not land at intended or alternate aero­ vital actions and detracts from the careful dromes, most probably we will be sitting on lookout essential for safety in coming into some landing strip on or near our route, strange aerodromes. (Editorial Note:­ which has no communication facilities. Our Whilst conceding that Dr. Haldeman's plane has a stalling speed of forty miles per views on the carriage of radio equipment .. hour. The next probable place that we will were conditioned by the unusual require-

5 4 ments for a flight through many countries, have many other things to watch, light the Department considers that there are signals of short duration may be overlooked. advantages to be gained from the use of Over desert stretches we will circle inter­ PART II i·adio in light aircraft on travel flights mediate aerodromes where there is a look­ within Australia). We are used to much out and also the first aerodrome after a heavier air traffic than anything that will water crossing. OVERSEAS ACCIDENTS be experienced on this route. Unless we are informed there are regulations otherwise At each stop we would like to obtain we will come directly to the aerodrome and location of intermediate landing strips not start a close in left-hand circuit at one on our maps, and conditions of these. All we thousand feet which will be completely out want to know about the weather is - is Super Constellation Inadvertently Ditches In Shannon River, Ireland of the way of heavier aircraft . When we there now, or likely to be, any surface winds find that everything is clear for us to come over forty m.p.h., or any cloud on the ground en-route or place of next landing. (This summary is based upon the report in, we will let the wheels down and start our Anything else we will cope with as we find circuit for a landing. If there is someone in of the formai investigation published by the tower and we are doing alright, we will it or return to the nearest aerodrome. the Depa1·tment of Indu&try and Commerce, expect a steady green light, if we are not, We appreciate any assistance given us Ireland.) we will expect a steady red one. Will acknow­ and will endeavour to co-operate in meeting ledge lights by dipping the wings. As we local requirements." N 5th September, 1954, at 0230 hours and is bounded at the north-western end by (local time) a Lockheed Super Constel­ an embankment rising to 14 feet above the Olation owned and operated by K.L.M. runway level and marked by red obstruction Royal Dutch Airlines, designated Flight 633 lights. Amsterdam to New York, took-off from Shannon River Airport, Ireland, for Gander Tidal waters in the Shannon Estuary ex­ Airport, Canada. A crew of ten, forty-six tend to this embankment leaving, at low Surface Conditions At Outback Aerodromes passengers plus cargo were on board. water, an extensive area of mudflats through which run several gullies and 1795/54 2844/54 Take-off from Runway 14/32 to the creeks. ROM time to time aircraft operating received that an earlier inspection is needed. south-east appears to have been normal up So far as could be determined there was into ren1ote aerodromes in the outback However, it is very difficult in sub-tropical to lift off speed (V2). Thirty-five to forty no pre-crash failure or malfunctioning in Fareas of Australia and in Papua-New or tropical areas to anticipate the rate of seconds later an inadvertent, but almost any of the engines and the indications were Guinea suffer damage or delays which can grass growth or ground erosion because perfect ditching had been made in the River that all four were under power at the time be attributed at least in part to poor aero­ rainfall is often irregular and poorly re­ Shannon, 8,170 feet from the departure end of the runway used. Twenty-eight lives of impact. Although some portions of the drome surface conditions 01· even to deterio­ ported. Most of these aerodromes are used aircraft structure could not be examined rated aerodrome markings and windsocks. frequently by pilots between regular inspec­ were lost and the aircraft eventually be­ thoroughly, since they were under water, Sometimes the grass is dangerously long or tions and it would be of great assistance if came a total loss through the effects of there was no evidence of structural failure, perhaps erosion gullies, ant-hills or areas of they would report immediately any condi­ ditching, exposure and salvage operations. instrument failure or system malfunction. poor drainage have appeared. On occasions tion of an aerodrome which has, or could The pilot in command, who was 49 years However, it was apparent that the wing we believe these ant-hills have appeared adversely affect the safe operation of air­ of age, had accumulated 18,884 hours of flaps were in the "up" position and that overnight but other types of deterioration craft. Steps can then be taken to ensure aeronautical experience, including 174 At­ the left main was "up" and can usually be detected over a longer period. that Notam information is accurate and lantic crossings with the company and was locked, whilst the. nose and right main gear It is often evident that prior to the inci­ that the aerodrome is restored to full ser­ endorsed on a number of modern heavy were not locked "up" at impact. dent the pilot involved, or other pilots have vice~bil ity as soon as possible. transport aircraft types. The , 31 operated at frequent intervals into the The gross load of the aircraft was well Because of the frequency of their visits years of age, had accumulated 5,317 hours within the maximum allowable for take-off particular aerodrome when signs of the de­ including 77 Atlantic crossings and was en­ terioration must have been apparent but and their appreciation of minimum service­ and the centre-of-gravity was within accept­ dorsed as pilot in command of DC.3 CV.240 able limits. have not been reported. ability requirements pilots· are ideal ·report­ and CV.340 types and as co-pilot on L.749 These outback aerod1·omes are inspected ing agents of aerodrome conditions and we and L.1049 types. Reconstructing the take-off operation it by aerodrome maintenance officers at pre­ would appreciate your co-operation in this The weather at the time of the accident is apparent that the. aircraft was airborne determined intervals unless any report is way. can only be described as nearly perfect at 125 knots (just above V2 speed) after a since there was broken cloud at 8,000 feet, ground run of 4,000 feet. As the aircraft visibility was 25 miles and the wind was passed over the remaining 2,450 feet to the 140 degrees, 12 knots. embankment the undercarriage commenced to retract and the embankment was Runway 14 at Shannon Airport is 5,643 crossed at rather a lower height than feet in length, is three feet above sea level normal. Almost immediately, a somewhat

7 6 steeper climb was initiated and METO power an immediate and direct bearing on the of sufficient safety against all known take­ matically inflated as a result of ordered at 140 knots. An eyewitness final disaster began to develop at the off risks. On this point it was determined impact damage. They could have described how the initiation of this steeper moment of retraction, that is only that the true height of the aircraft was easily floated away beyond recovery.) climb was followed almost immediately bY, about 15 seconds before the moment of con­ never more than 170 feet and the discrep­ a shallow descent. However, this was ap­ tact with the water. The first indication of ancy between true and indicated heights (e) "That flight personnel and all other parently not noticed in the cockpit and at the necessity for corrective action by the was probably due to the cumulative effects services concerned be made aware 150· knots flap was ordered "up". At 160 pilot in command should have been given by or instrument error, setting erro1· of the extreme danger of fumes in a knots climb power was ordered and a feW'. his artificial horizon displaying a definite and position error. confined space, such as the cabin of seconds later the aircraft made first con­ lowering of the nose, though not indicating an aircraft resulting from ingress tact with the water this being some 31 a nose-down attitude. The occurrence of The Court found that the accident was (or in-flow) of petrol." (In this seconds after it passed over the end of the this attitude change, notwithstanding a due to the following causes:- accident 26 of the 28 deaths were runway. positive nose-up correcting action for flap due to asphyxiation by petrol fumes.) (a) Failure of the Captain properly to co­ The aircraft came to rest on a shallow retraction taken by him several seconds earlier, must very probably have been pro­ relate and interpret his instrument (f) "That portable oxygen equipment for mudbank, 8,170 feet from the end of the indications during flap retraction, re­ emergency use by more than one runway, and sustained major damage to moted by the fact that the landing gear was ., in the course of re-extension, and possibly sulting in necessary action not being crew member be available on trans­ the . The highest altitude observed taken in sufficient time. This failure port category aircraft." (Rescue by the pilot in command during the flight the fact that the pilot-in-command did not retrim the aircraft for flap retraction. was partially accounted for by the operations by the crew members was 250 feet and just before the crash he effect on instrument indications of in­ were hampered by the shortness of observed an altitude of 100 feet with the Even if the change of attitude to a more advertent and unexpected landing the periods they were able to stay in climb and descent indicator showing a or less level position had not been noticed gear re-extension. the cabin.) descent rate passing through 1,000 feet per immediately by the pilot in command, the (b) Loss of aircraft performance due to minute. The pilot in command took im­ first indications of a descent could have mediate recovery action by pullmg the con­ inadvertent landing gear re-extension. The first positive indication that this air­ been noticed about three seconds later on craft had crashed was received at 0512 trol column back but at that stage nothing the altimeter. The fact that at the moment could have prevented an accident and his (c) The Captain failed to maintain suf­ hours (i.e., 2 hours 34 minutes after the a scan of his instruments did not reveal an ficient climb to give him an oppor­ take-off) when a survivor arrived in a dis­ action fortunately prevented a heavier undesirable flight condition must be ' at­ impact. tunity of meeting unexpected occur­ tressed condition at the airpol't fire station. tributed to one or both of the following rences. Rescue operations were commenced im­ The Court of Investigation has stated causes. mediately and proceeded generally in a satis­ that after take-off the landing gear should The Court also made recommendations factory manner. Neither the afrport con­ be up and locked before flap is retracted. (a) After the first five or six seconds, arising out of the evidence presented and troller nor the fire station look-out watched The fact that flap was found to have been when he is accustomed to less con­ some of these were- the aircraft out of sight because they tinuously scan his instruments, the retracted, whilst two units of the landing (a) "That warning or signal lights in­ turned away to perform the departure gear were not locked up, indicates that this pilot in command's observations of the logging and notification duties. Despite the horizon and the altimeter movement dicating an unlocked or transient procedure was not accomplished. However condition of the landing gear as on fact that the aircraft did not respond to the bulb of the red indicator lamp, indicat­ were inadequate; he placed too much radio calls after departure the fears of the reliance on the slow reacting climb the Lockheed 1049 Super Constella­ ing the landing gear to be unlocked and/ or tion, be duplicated." airport controller for the immediate safety in a transient condition was found to be and descent indicator. of the aircraft were allayed by a statement burnt out and it was accepted that this had (b) "That self-sufficient emergency light­ from the G.C.A. Director that he had picked occurred _during retraction giving a false (b) He did not appreciate, to the full ex­ ing be provided in passenger accom­ tent, the anticipating character of the up an outbound "blip" at 23t miles west at indication of landing gear "up". It was modation of transport categor y air­ 0248 hours (i.e., 10 minutes after take-off). also found from tests that if, in this type horizon indicat10n in that a change of the horizon bar position indicates craft." (This stemmed from the fact aircraft, flap is select~ whilst the landing that the aircraft was plunged into No blame was attached to the airport gear is in the retracting stage, the flap will a change of flight conditions which will not become apparent from the darkness immediately after impact controller or fire station look-out for not first retract, delaying the landing gear and thus hampering evacuation and continuing to observe the aircraft but the in some cases allow re-extension. It is quite other instruments until some seconds later. rescue.) . Cour t considered that a grave error of possible that this did occur, thereby caus­ judgment was committed by the G.C.A. (c) "That flash lights of flight crew per­ ing unexpected drag, creating a condition Director in identifying a "blip" with this wholly unexpected by the pilot in command. The Court also formed the opinion that sonnel be so designed that they may the pilot in command did not utilize the be functional while leaving the hands aircraft without qualifying the report that However the performance of this type air­ the path of the aircraft had not been fol­ craft is such that this situation could climb performance of the aircraft to the free." extent possible. If he had concentrated less lowed from the vicinity of the airport and reasonably have been handled with adequate (d) "That flight personnel be made aware had, in fact, only been seen on the screen safety and therefore, this condition con­ on building up speed and more on gaining height in take-off, he would have had a of the danger that power-on ditching for some ·~en seconds duration. tributed to, rather than caused, the may remove power plants from the accident. better opportunity for coping with unex­ pected incidents. He was at a further dis­ wings in turn causing damage to the The Court made several recommendations In endeavouring to provide an explana­ advantage in dealing with unexpected wings and possible loss of dinghies for improvements to ground services and tion of the accident the Court drew atten­ hazards in his assumption that 250 feet stowed therein." (In this accident facilities at Shannon Airport based on the tion to the fact that the events which had indicated altitude placed him in a position two dinghies were released and auto- evidence presented in the investigation.

8 9 Fuel Exhaustion in DC.3 Near Pittsburgh, U.S.A. the filed CAA flight plan or the com­ excess of that shown on the weight pany flight plan ; and errors in ground and balance form. (This sum1nary is based upon the report speed calculations and estimates of up to 22 knots. (k) The baggage in the rear compartment of the Civil Aeronautics Board, U. S.A., was found to weigh 58 lb. more than released on 8th April, 1955) (18/27/56) ( e) A carefully prepared flight plan would the maximum permissible load for have indicated a total time interval this compartment. However, the N 22nd December, 1954, a Douglas swim and the icy waters made it difficult for the flight of 2 hours 7 minutes centre-of-gravity of the aircraft was DC.3 departed Newark, New Jersey, for even good swimmers to reach the shore. instead of 1 hour 40 minutes as within permissible limits. planned. 0 for Pittsburgh, Pennsylvania, a The pilot in command and nine passengers. (1) It was obvious that the aircraft was distance of some 270 miles. The aircraft were drowned. overloaded at take-off but it was not was owned by a civilian operator, manned (f) The cruising power used on the flight The aircraft was subsequently recovered was 100 h.p. higher than that laid possible to determine precisely the by a civilian crew of five and was carrying amount of overload. 23 military personnel and their baggage. and the examination revealed that both the dqwn in the company operations The flight departed at 2038 hours (local aircraft and engines were capable of normal manual. The investigating authority remarked time) and on flight plan was due at operation at the time of the accident. This that "it is incredible that an air carrier air­ was confirmed by the co-pilot's statement (g) The co-pilot on this flight had been Allegheny County Airpo1·t, Pittsburgh, 1 hired by the pilot in command only craft flown by accredited personnel could be hour 40 minutes later. The weather over that the engines and aircraf t functioned in forced down for lack of fuel on a short a nor mal manner throughout the entire five days previously and had received the entire route was fine and the flight was no ground training nor taken the night flight in good weather when we think to be made in accordance with the visual flight. There had been no prnviously repor t­ of the great progress aviation has made to ed defects in the fuel system and the ex­ written examinations required by the flight I'llles. According to the weight and company's operations manual. clate, particularly with respect to pilot balance manifest the aircraft carried 225 amination confirmed the fact that the fuel training, aircraf t instrumentation, naviga­ gallons of fuel (company flight plans at had been exhausted. (h) Although the weight and balance tional aids and airport lighting". 80 g.p.h.) and the all-up-Weight was 29 lb. The investigating authority has stated manifest indicated that 225 gallons of The significant findings were- under the maximum permissible. that "the general conduct of this flight fuel were being carried, the accuracy En-route the flight encountered winds, clearly indicates poor j udgment, careless­ of this figure could not be conclusively (i) The company did not properly check substantially as forecast, but on passing ness and lack of supervision and training." established but, at least, this quantity the competency of the crew in accord­ Philipsburgh (an available refuelling point) In this regard the following factors revealed was not sufficient for a safe flight ance with their operations manual the co-pilot advised the captain that to con­ in the investigation are wor thy of note :- from Newark to Pittsburgh by any p~·io1· to flight assignment. tinue without refuelling would involve the route; considering the distance flown (a) The pilot in command of the flight was and all other known factors affecting (ii) The aircraft was overloaded at time use of fuel reserves. The captain decided a company check pilot with 7 ,tiOO fly­ of take-off. to continue but, on reaching the vicinity of fuel consumption it is calculated that ing hours including 1,500 hours on the approximately 260 gallons of fuel Johnstown airport, he advised Pittsburgh DC.3 type. All of the other crew mem­ (iii) The flight was improperly planned of his fuel shortage and endeavoured to were consumed. This would have and was not conducted in accordance bers also had substantial flying hours made the aircraft overloaded at take­ locate Johnstown. He was unable to do so, in total and on the DC.3 type. with the company's operations manual. despite the use of A.D.F. facilities and the off. (b) The pilot-in-command filed a fl ight (iv) The captain, contrary to the com­ fact that all the airport lights were on, and (l.) The crew baggage (for five persons) pany's operations manual passed a so the aircraft continued to Pittsburgh. plan by telephone before departure to was not included on the weight and fl y over a route which had been dis­ suitable refuelling facility after being balance manifest as was required by advised that, if the flight continued The aircraft approached Allegheny continued for more than a year. the operations manual and to this County Airport, Pittsburgh, at 3,200 feet to its destination, it would be neces­ (c) No written flight plan or navigation extent the aircraft was further over­ sary to use reserve f uel. and was cleared for a straight in approach. log was prepared before departure. loaded. The pilot reported three miles out on final This was corrected by the co-pilot af­ (v) The probable cause of this accident app1·oach and a minute later that his fuel ter departure but without consulting (j) The passengers baggage was re­ was fuel exhaustion brought about by was exhausted, both engines were feathered, the pilot in command as to his inten­ covered in a clean condition, thoroug·h­ inadequate flight planning. Con­ he had two miles to go and he doubted tions. Consequently, a route, different ly dried and weighed. The total tributory factors were inadequate whether he could reach the runway. The from that notified .verbally by the cap­ weight was found to be 260 lb. in crew supervision and training. captain then advised "we are going to set tain, was entered on the flight plan it down" and the aircraft was observed from the control tower to turn away from and followed by the aircraft. the airport and disappear behind some low (d) This flight plan and navigation log Emergency Landing In Convair 340 As Result Of Elevator Failure hills. It was ditched at 2300 hours in the prepared in the air included many Monogahela River, and the aircraft sank mistakes such as; wind velocities dif­ .. (This sumniary is based upon the report after about fifteen minutes. None of the fering from those forecast; a higher of the Civil Aeronawtics B oard U.S.A., re­ passengers or crew received injuries during true airspeed than is reasonable to ex­ leased on 7th September, 1955) the ditching and the occupants evacuated pect of a DC.3 at 4,000 feet; some the cabin via the emergency exits onto the stations, courses and radio frequen­ N 19th J anuary, 1955, a Convair 340 emergency landing in a snow covered corn­ wings. Some of the passengers could not cies were not consistent with either aircraft owned and operated by field 30 miles west of the depar ture airport, OUnited Airlines Inc. made a wheels up Des Moines, Iowa. There were minor 10 11 ~n~ur~es to some of the 36 passengers, no to the right for an additional 1,485 feet. checked by ~h.e supervisor and inspector on the job card and that the relieving crew mJunes to the crew, but the aircraft was The was crushed, the propellers and, being confirmed, the job card was chief be briefed on all w9rk performed dur­ substantially damaged. and engine mounts broken and the main­ signed off. ing the foregoing shift. These procedures plane leading edges dented. The snow which were not followed in this case. The aircraft departed Des Moines for It appears that during the subsequent was uniformly five or six inches deep on operation of the aircraft the unpinned Omaha, Nebraska at 1608 hours at a gross the ground considerably lessened the The fact that the final inspection did not weight 1685 lb. less than the maximum castellated nut backed off the idler support reveal any play in the elevator servo tab damage the aircraft received during its bolt, because of vibration, allowing the bolt permissible of 46,900 lb. The climb was un­ slide. assembly can be explained by the chance eventual until at 5,000 feet the crew noticed to free itself from th~ outboard of the two rotation of the bolt during· its removal and vibration and a slight fore and aft move­ The captain, aged 35, had a total of supporting brackets which it traverses. replacement. However since the job card ment of the control column. The aircraft 7 ,578 pilot hours of which 750 hours were With the idler then suppor ted only. by the had been written up for work to be done was levelled off at 6,000 feet and a number in the Convair 340 type. The first officer, bolt traversing one bracket, forces were and there was no entry to indicate that of measures tried in an endeavour to aged 29, had a total of 2123 pilot hours exer ted which hroke the bolt one inch from such work had been done it was considered eliminate the vibration, without success. of which 1147 hours were in this type. The the head. This allowed the idler to drop that the inspector should have made a more Suddenly a failure in the control system aircraft had a total of 1502 hours since l' down and the servo tab began to oscillate thorough inspection of the servo tab system. was felt and it was with extreme difficulty new. causing the initial vibration felt in the cock­ Nevertheless, the critical omission was the that any semblance of elevator control was pit . Loads were then induced in the rear failure to write an explanation on the job The section of the aircraft push pull tube causing it to fail leaving the maintained. Various flap settings were tried was intact and virtually undamaged by card that the bolt had been removed and to help in maintaining control and the best tab to oscillate without restraint and this replaced only finger tight pending the ground contact. During an examination of in turn caused the por t elevator to oscillate results were obtained at the 15 degree the elevator torque tube assembly it was arrival of a new bolt. position. A distress call was initiated on about its hinge line. The resultant loads observed that there was a vertical fracture caused by the port and starboar d elevators The investigating authority believes that the radio and an attempt to return to Des on the right side. This completely discon­ Moines was commenced. being out of phai:ie broke the starboard the crew was confronted with an extremely nected the starboard elevator from the torque tube connection plate thus prevent­ hazardous situation and that it was only by The buffeting soon became so severe that main torque tube assembly but the port ing cockpit contr ol of the starboard elevator. employing the utmost judgment and skill it was necessary for the first officer to help elevator was still attached to the assembly The port elevator torque tube assembly was that a disaster was avoided. the captain hold the control column. The and partial elevator control could still. be also deformed resulting in almost negligible aircraft was de-pressurized and the pas­ effected. It was also discovered that the contrcl of this elevator from the cockpit. It was concluded that the probable cause sengers prepared for an emergency landing. aft push-pull tube attached to the port A thorough study of the operator's main­ of the accident was a series of omissions By this time the aircraft had descended elevator servo tab horn had broken trans­ tenance procedures revealed that they were made by maintenance personnel during a below 3,000 feet and both were versely about 12 inches forward of its rear adequate but had broken down because of scheduled inspection which resulted in the i·etarded in turn to test if the engines were terminal and this had allowed the tab to the frailties of the human element . The release of the aircraft in an unairworthy the source of the vibration, without avail. oscillate violently and over travel, tearing operator's procedures required that an ex­ condition and an almost complete loss of The vibration built up to a high level and rearwards the tab hinge cutouts. planation of all work performed be written elevator control during ftigh t . suddenly another failure in the control On opening the inspection doors it was system was felt and the aircraft went into also found that the servo tab idler was a steep climb. As it seemed that a stall was completely detached from its support in the imminent the captain quickly moved the elevator, a~ the supporting bolt had frac:­ propellers to a high r.p.m. and opened the tured. The associated nut and washers were throttles to approximately 50 inches of found loose in the elevator but the cotter manifold pressure. The aircraft then nosed pin could not be found. over and began to dive at a very steep angle. During this rapid descent the cap­ An investigation of maintenance work tain reduced power and headed towards done on this aircraft on the day preceding open country. When the aircraft reached the accident revealed that excessive play 500 feet above the ground the captain was in the elevator servo tab had been noticed successful in flaring the aircraft and it and this traced to considerable wear in the struck the ground in a flat attitude. The idler support bolt. As a replacement bolt aircraft came to rest m an upright position was not immediately available and had to with its wheels retracted in a level snow be ordered the mechanic had, under instruc­ covered cornfield. tion, replaced the worn bolt with the nut finge1· tight and not pinned. No explana­ Th e ground markings indicated that the tion of this temporary replacement was aircraft had first contacted the ground, level entered on the job card. At the subsequent laterally and slightly nose-high. At the change of shift the oncoming crew chief second contact point 900 feet further on was not briefed with respect to the worn the aircraft had bounced over a barbed wire bolt and the new mechanic assigned to the fence for a further 390 feet, hurdled job reported that he could find no excessive another fence and skidded in a slight curve play in the servo tab assembly. This was

12 13 locking. As t he only positive means of this accident the company has int r oduced establishing t hat the undercarriage is precise instructions in t he operation of the PART Ill spring locked is by obtaining green lights undercarriage. and/ or no warning horn, it is apparent that the latch should not be placed in the posi­ Although the performance of the DC.3 tive lock position until such an indication is such that height can be maintained on AUSTRALIAN ACCIDENTS is obtained. The usual practice is to engage one engine with the under carriage lower ed, t he positive lock when the desired pressure it is desirable to delay lowering the under­ is registered and check the light later. This carriage until the act ual descent for landing procedure is satisfactory as the desired is commenced in order to avoid applying DC.3 At Sydney, N.S.W. - Undercarriage Collapse pressure almost certainly indicates that the considerable power to the good engine. The undercarriage· is spring locked. However, operations manual of the company concer ned (1208/53) in this instance, the check captain returned specifies that, on a single-engine l andin~·, the lever to neutral before the desired pres­ the undercarriage must be lowered on t h <:l sure had been built up and, therefore, he base leg, which permits it to be lowered, DOUGLAS DC.3 sustained minor pilots observed that the undercarriage could not be reasonably certain that the locked and checked at a safe altitude. From damage when the undercarriage col­ warning lights were showing red, where­ spring lock was engaged and he should the testimony of the pilots it appears that. A lapsed, during the landing roll, fol­ upon the check captain r eleased the under­ have checked for green lights before plac­ on this occasion, the lowering of the under ­ lowing a practice single engine landing at carriage latch and placed the selector lever ing the latch in the positive lock position. carriage was purposely delayed until t he Sydney (Kingsford-Smith) Airport, New in the down position. He then immediately In this regard he may have been misled by aircraft was turning onto final because con­ South Wales. No one was injm·ed. selected flaps down. Towards the end of the company's operations manual which, siderable drift was experienced on t he base the landing roll and as the brakes were under landing gear management, lists leg, which suggested to them a st rong The Circumstances applied first the port, then the starboard "undercarriage positively latched" before headwind on final. However, the recorded undercarriage, slowly collapsed. "check lights'', which, as shown above, is wind strength at the tin1e of the accident After an engine change earlier in the day not strictly correct. was only 15 m.p.h. Furthermore, it appears the aircraft took off from Sydney Airport Discussion of the Evidence from the evidence of the captain-under­ for a test flight. It was under the command When the check captain realized the check, that he did not have time, after he of a company check captain, occupying the No defects or evidence of malfunctioning undercarriage was not locked down, after called for t he undercarriage to be lowered, right hand pilot seat, whilst a company of the undercarriage or main hydraulic his premature manipulation of the levers, to properly check that it was down and captain, who was being given a periodical system were found during the inspection he again selected down. From the fact that locked before having to concentrate on the flight check for his licence renewal, flew carried out after the accident. The engine the undercarriage did not collapse until the landing. In view of the evidence that t he the aircraft from the left hand seat. The pump selector lever was apparently in the brakes were applied it is apparent that it undercarriage was functioning normally take-off and a series of manoeuvres were normal position, i.e., port engine (operative was almost fully extended on touch down. during the approach, it is considered' more carried out by the captain-under-·check, engine) to main hydraulic system, during Therefore, it is considered that, if the likely that the low pressure was occasioned under the blind flying screens, culminating the approach and thus maximum and con­ lowering of the undercarriage had not been by the relative closeness of the aircraft to in an A.D.F. app1·oach to the minimum tinuous pressure would have been available arrested by the premature completion of t he runway when the undercarriage was altitude. At this stage the screens were for the operation of the undercarriage. The the drill, there would have been sufficient selected down. Furthermore, the fact that removed and the aircraft joined the down­ evidence indicates t hat the undercarriage time for it to have been fully extended and there was very little time for any appr op­ wind leg of the aerodrome circuit for a was not mechanically locked on landing and, locked prior . to touch down. riate action to be taken when it was landing on Runway 16. After requesting although hydraulic pressure apparently sup­ realised that the undercarriage was not and obtaining permission from the airport ported the undercarriage during the early It appears from the evidence that the locked prior to landing indicates that it was controller to carry out an asymmetric land­ part of the landing roll, the application of check captain was unduly concerned with selected down at a relatively late stage of ing, the check captain feathered the star­ t he brakes and the consequent rotatiye returning the selector lever to neutral and t he approach. Therefore, it is considered board propeller and instructed the captain­ force on the undercarriage suspension over­ engaging the positive lock, which suggests that the undercarr iage was initially selected under-check to proceed with the landing. came the hydraulic pressure and resulted that he considered these operations were down at a stag~ when there was barely As the aircraft was turning onto final the in the undercarriage collapsing. vitally necessary to lock the undercarriage. sufficient time for it to be fully extended, captain-under-check called for the under­ As previously discussed, the spring lock locked and properly checked prior to land­ carriage to be lowered and the check cap­ The check captain, after initially select­ automatically effects the essential locking ing. tain promptly placed the selector lever in ing the undercarriage down, returned the of t he undercarriage and premature opera­ the down position. The check captain states selector lever to neutral before the undercar­ tion of the selector lever serves no purpose that the undercarriage hydraulic pressure riage pressure had built up to the desired unless the undercarriage is spring locked Both pilots involved in this accident held appeared to be slow in building up and as figure and then engaged the positive lock whilst premature operation of the latch will 1st class airline transport pilot licences and the aircraft, at this stage, was nearing the before checking t hat the undercarriage prevent the spring locks from engaging. had accumulated considerable experience on runway he elected to land without full pres­ warning lights showed green. The action of Therefore, it is considered that if the check DC.3 type aircraft. The check captain had sure and returned the selector lever to placing the undercarriage latch in the posi­ captain had been fully familiar with the been on duty for ten hours on this day, in­ neutral and placed the undercarriage latch tive lock position, before the undercarriage 1 functioning of the undercarriage he would, in the positive lock position. As the air­ is fully extended and the spring engaged, has as time was critical, have left the selector cluding 6.20 hours of flying duty and t his craft neared the runway threshold both the effect of preventing full extension and J lever in the down position until the desired factor could have affected his concentration pressure had been built up. As a result of during the flight. 14 15 ,-

Conclusions After take-off, at about 1015 hours, the these officers recall the leader mentioning Sea Furies made formation over the aero­ that he proposed to fly over Uranquinty be­ 1. The cause of the accident was the in­ drome and were lost to sight flying at a fore setting course for N owra and he was correct manipulation of the undercar­ low altitude towards Wagga township. told by the airport controller to call on the riage by the pilot in command, which radio should he wish to re-enter the Wagga resulted in the aircraft landing with the Shortly after the departure of the forma­ control zone. The formation did not fly undercarriage not mechanically locked. tion a civil DH.82, being flown by a student pilot, was given permission to take-off on over Uranquinty and, during the eight 2. A contributory cause was an enor of minutes between take-off and the accident, practice circuits and landings. The take-off they flew over W agga township and back judgment on the part of the pilot in was made on the grass strip into the north­ co1mnand in failing to ensure that the east. The aircraft became airborne approxi­ over Forrest Hill aerodrome which was ap­ undercarriage was lowered and locked mately halfway along the strip and the proached from the vicinity of Lake Albert, prior to being committed to a landing. climb was continued straight ahead. Whilst some two miles to the west. 3. The incorrect manipulation of the the DH.82 was still over the aerodrome at The control tower received no radio undercarriage by the pilot in command a height of about 150 reet, the airport con­ signal from the Sea Furies after the take­ The Naval Sea Fury formation closes on the was apparently due to his lack of know­ troller received a radio call from the forma­ off until the call from near the aerodrome DH.82 from the rear over the building area at ledge of the functioning of the under­ tion advising that they were setting course boundary when it was too late to issue Wagga aerodrome. Note that the pilots of the caniage system. three leading aircraft have not seen the DH.82 for Nowra. At the same moment he looked instructions or information to the aircraft but apparently Nos. 4 and 6 of the formation 4. Fatigue and/or pre-occupation may pos­ up from briefing a visiting pilot and saw before the collision. have and are commencing to "break" to star­ sibly have contributed to the poor air­ the Sea Furies close to the south-west board. manship displayed by the pilot in com­ boundary of the aerodrome at approximate­ At least one member of the formation mand. ly 150 feet and heading across the aero­ saw the DH.82 immediately before the col­ 5. The captain-under-check made an error drome. They were flying at about 250 knots lision, but it seems highly probable that of judgment in delaying the lowering of and in the same direction as the DH.82 the leader did not. Contributory factors the undercarriage until the aircraft was which was ahead and slightly Lelow them. may have been the pilot's poor visibility so close to the runway that there was immediately below and ahead of a Sea Fury, ,~ ..t,, The aircraft closed without either the ... barely sufficient time for the under­ or the temporary diversion of his attention DH.82 or the formation leader changing to onlookers on the tarmac. carriage to be lowered, locked and pro­ course and the leading Sea Fury hit the perly checked prior to landing. DH.82 from astern and below with its pro­ The pilot of the DH.82 did not suspect peller, cockpit canopy and fin. the presence of the other aircraft, and from Mid-air Collision At Wagga, N.S.W Three photographs, taken independently the time he took off until the noise of col­ (410/4/95) by amateur photographers, are reproduced lision made him realize that something was on page opposite and show the aircraft amiss, he was concentrating on a steady l<'ORMATION of six R.A.N. Sea Furies immediately before and after the collision. straight ahead climb. took off from Forrest Hill aerodrome, A Wagga, for local flying and return to their base at Nowra. Soon afterwards, at Discussion of the Evidence Conclusion about 1020 hours, they r eturned over the Neither the R.A.A.F. liaison officer, who The cause of the accident was that the aerodrome at low altitude where the leade1· accompanied the leader of the formation to leader of the formation led his aircraft back collided with a civil DH.82 which had pust the control tower prior to the take-off, nor over the Forrest Hill aerodrome without taken off on local flying practice. the airport controller were aware of any indicating his intention to do so and with­ The DH.82 crashed on the aerodrome, the arrangement for a fly past at Forrest Hill out maintaining a lookout adequate to In the view below the formation leader has by the Naval formation, nor was it men­ prevent collision with other aerodrome just hit the DH.82 with propeller, canopy and pilot escaping serious injury. The Sea Fury fin whilst Nos. 4 and 6 continue breaking away. crashed two miles away and the pilot was tioned in the flight plan. However, both of traffic. In the view above the DH.82 is seen dis­ killed. integrating further whilst the damage to the leader's fin and is visible, Norseman - Undershot And Overturned Events Preceding the Accident (410/ 6/ 44) Prior to take-off, the leader of the forma­ tion visited the control tower where the S a Norseman aircraft was levelling out Vanimo airstrip runs across an isthmus flight plan was filed and discussed with the to land on Vanimo airstrip New in a southeast-northwest direction. It is duty airpoi·t controller. The leader men­ AGuinea, the port wheel struck a some 200 feet wide and approximately 1,700 tioned that he would take the flight over stump just short of the airstrip and, on sub­ feet in length, terminating at each end on Wagga township and the Uranquinty area sequent touchdown, the aircraft nosed over a beach. At the time of the accident some before setting course for Nowra. As and came to rest inverted. The aircraft Uranquinty is outside the Wagga control sustained substantial damage and the pilot 300 feet at the northwestern end was zone, the airport controller requested the and two of the thirteen passengers received marked unserviceable and a Notam had leader to call the tower if and when re­ minor injuries. been issued advising pilots accordingly. turning to the zone. 17 The aircraft was on a charter flight from struck a stump protruding out of the sand The pilot had been operating in this area The findings of the investigation were:- Wewak to Vanimo and was carrying one approximately eight inches and just short for only three months and his experience European and 12 native passengers. The of the airstrip. The pilot felt the aircraft on DH.84 aircraft amounted to some 93 (a) The probable cause of the accident pilot was an experienced New Guinea pilot hit but continued with the landing. The hours in a total experience of 2,730. Opera­ was a loss of control during the and had landed some 50 times previously aircraft touched down on the airstrip some tions. in central Queensland in DH.84 types execution of a turn at low speed in on Vanimo airstrip, 11 times in Norseman 90 feet from the stump, ballooned for a require a degree of special skill and judg­ operating conditions which did not aircraft. This was his second flight into further 80 feet then, on touching down ment because of such common factors as provide an adequate margin of per­ Vanimo on the day of the accident and on again, nosed over and came to rest inverted. high density altitudes, turbulence, marginal fonnance; and (b) Contributory causes were:- the earlier flight he had taxied over that Examination of the wreckage revealed, airstrip conditions and the limited perform­ part of the airstrip declared unserviceable inter alia, that the upper torque link bolt ance capacity of the type. It is considered (i) The all-up-weight of the aircraft by the current Notam. on the port undercarriage was sheared - that the pilot's short experience of these was in excess of the safe maxi­ this had apparently occurred when the factors contributed to the accident in that mum; The flight from Wewak was uneventful wheel struck the stump. This damage per­ a combination of over-load, short strip and (ii) The limited experience of the and, after completing a circuit of Vanimo mitted the wheel to swivel out of track and, th0 extra aerodynamic loading of a circling pilot on DH.84 aircraft and airstrip, the pilot commenced an apprnach from the ground marks, was at right angles climb led to a loss of control at too low an in the operating conditions into the south-east. The weather was fine to the direction of landing on touch down. altitude for recovery to be possible. encountered during the flight. and the wind was from the north-east, i.e., This resulted in the wheel digging in and across the airstrip, at about 10 knots and causing the aircraft to nose over. gusty. The pilot intended to touch down ! Aerial Ambulance Aircraft Ditched In Sea at the extreme northwestern end of the air­ It was concluded that the cause of the strip, on the area marked as being unser­ accident was poor technique on the part of (18/3/1) viceable. The approach was made with the the pilot in that he landed short of the air­ port wing down to counteract drift. As the strip and damaged the port landing wheel OLLOWING an emergency call from position just south of Cooktown, the flight aircraft was levelled out over the beach in such a manner as to subsequently cause Cron Range, Queensland, an aerial was conducted above cloud with little or no preparatory to touch down, the port wheel the aircraft to overturn. Fambulance aircraft set out from Cairns ref~1-~nce to the ground. The pilot reported to bring in an aboriginal boy, suffering positions on track as the flight proceeded from snakebite, for treatment. The return and at 1946 hours he reported a contact Fatal Stall In DH.84 Dragon flight from Iron Range commenced at 1723 posjtion 33 miles north of Cairns and then hours and the E.T.A. Cairns was approxi­ at 2007 hours, "landing in ten". However (18/21/1) mately 2015 hours, last light occurring at on E.T.A. he reported that he could not see approximately 1840 hours. On board the Cairns and in a subsequent search of 18 DH.84 Dragon flown by a licensed The density altitude at the time of take­ aircraft were the pilot, an ambulance mi_nutes .he st~ll fail~d to locate it. During airline transport pilot was engaged off was approximately 6,000 feet and bearer and the patient. The aircraft a tlus period, direct lrnk communication was Ain transporting a medical practitioner Cheviot Hills airstrip is 2,700 feet in length, DH.89A Rapide, was equipped with a radio established between the air traffic control on his routine rounds to scattered settle­ i.e., 400 short of the minimum length of and was licensed only for visual units at Cairns and Townsville and the ments in central Queensland. The aircraft run for this type aircraft as required flight. However, in operations of this situation was discussed. At 2036 hours the took-off during the afternoon from Cheviot by AIP/ AGA-4. At the time of the accident nature, it is expected that an occasional remaining endurance of the aircraft was Hills airstrip with the intention of return­ the only specific limit upon the operating emergency night flight will be necessary 107 minutes (based on flight plan endurance ing to base at Charters Towers. In weights of DH.84 aircraft was that con­ and this is acceptable provided that of 300 minutes) and the pilot stated that addition to the pilot, the occupants of the tained in the · certificate of airworthiness. weather conditions are favourable and he was setting course back to Cooktown aircraft were the doctor, his wife, and a In this case it was 4,500 lb. and the actual navigation facilities are adequate. (90 miles distant). small boy being transported to Charters weight at take-off, 4,286 lb., was well within Towers for medical treatment accompanied this limit. However, both the Department The pilot held a third-class airline trans­ Air Traffic Control at Townsville, sug­ by his mother. and the operator had advised pilots to take port licence and had 119 hours experience gested to the pilot that, as the weather at account of circumstances which would on DH.89s in a total experience of 6665 Townsville was favourable and in that The take-off was carried out in wind con­ affect the pedormance of the aircraft and hours. At the commencement of the return direction lay much better radio and visual ditions which were generally calm but in to determine a safe weight for each parti­ flight he was undecided whether to land at ~avigation aids, he might consider attempt­ this area some turbulence would be ex­ cular operation accordingly. The Depart­ Cooktown, just after dark, or to continue to rng to reach Townsville. This the pilot pected in the afternoon. Soon after becom­ ment was preparing a take-off weight chart Cairns where the nearest medical practi­ agreed to do and, after flying towards ing airborne the aircraft commenced a for DH.84 aircraft at the time of the tioner was located. As the patient's con­ Townsvill~ for 21 minutes, HDF bearings gradual climbing turn to starboard and, accident and when this was subsequently dition worsened and a terminal forecast for were obtained at Townsville indicating that when the aircraft had turned through ap­ published the maximum safe weight for Cairns was received indicating a cloud base the aircraft was some 40 p1iles off the coast proximately 180 degrees the starboard wing take-off on this occasion as determined from of 1200 feet and visibility 10 miles, the north of Townsville. The aircraft was due dropped and the aircraft entered a steepen­ the chart, was 4,050 lb. In the light of this pilot decided to overfly Cooktown and pro­ at Townsville at 2206 hours with an ing dive until it struck the g-round at a more specific information, it was apparent ceed to Cairns in an endeavour to save the apparent reserve of 17 minutes but at 2141 very steep angle. The aircraft was w1·ecked that the all-up-weight of the aircraft was life of the patient. hours the pilot advised he was descending by impact forces. The pilot and the doctor's 236 lb. in excess of the safe maximum hav­ and almost out of fuel. wife sustained fatal injuries and the other ing regard to the circumstances of the The aircraft was cruising at 7,000 feet The aircraft was ditched in the sea some occupants escaped with only minor injuries. operation. and the evidence indicates that, from a sixty-two miles north of Townsville off

18 19 Hinchinbrook Island at approximately 2155 night and it is considered that the proper conditions had not . been provided, craft in IFR conditions. It is considered hours. The aircraft sank quickly and the action would have been fo land at Cooktown. either by the pilot's employers or the that, by a complete exchange of informa­ patient, who could not be extricated, was owners of the aircraft. tion commencing from the earliest possible drowned. The pilot who was apparently Nevertheless, there was a very real pres­ time, a large measure of assistance can be injured in the ditching, escaped, but sub­ sure on t he pilot arising from the patient's (f) The pilot underestimated the fuel consumption of the aircraft. provided to the pilot in these circumstances. sequently drowned and the ambulance deteriorating condition and it -is considered Similarly the aircraft operator has issued bearer was picked up by a passing ship that in making this decision, he was placed Since this accident the Department has further instructions in connection with some six hours after the ditching. in an unenviable position. The existence of issued instructions to both pilots and air emergency medical flights which should precise written instructions from his traffic controllers describing t he action they assist its pilots to decide whether, despite From the HDF bearings obtained on the employers or the ambulance organization must take when it becomes necessary in a the medical emergency, an IFR flight aircraft in the latter part of the flight, in dealing with circumstances such as this medical emergency to operate a VFR air- should be undertaken. conjunction with the known courses flown would have been of great assistance to him after setting course for Townsville and the and would probably have inftµenced him to ditching position· it appears that, when the land at Cooktown. The instructions that pilot estimated he was over Cairns, he was, did exist were of a general and verbal Take-off Accident - Moth Minor in fact, many miles south-east of this posi­ nature and there is some doubt as to tion. This suggests that the pilot's naviga­ whether they were conveyed to and under­ (1529/53) tion and position reporting on the flight stood by the pilot. from Iron Range to Cairns were inaccurate. MOTH MINOR, taking-off at Nhill until a turn onto course was commenced This, of course, was known to no-one but The aircraft's radio compass proved to be aerodrome, Victoria, became airborne shortly after becoming airborne and at a the pilot. The regular reporting of visual useless in locating Cairns, probably because Aafter a run of approximately 600 feet. relatively low altit ude. Thus, it appears "on-track" positions with no requests from of the combination of "nigl1.t-effect", at­ Before the aerodrome boundary had been that the t urn was entered with insufficient the pilot for special assistance led the ATC mospheric interference, and the inherent reached, a tight turn to port was com­ airspeed in view of the fact that the air­ organization to believe that the flight was range limitations of the particular airborne menced at a height of about 100 feet. Dur­ brake was extended, and in the gusty wind proceeding normally and would terminate equipment. ing the turn, the aircraft rapidly lost conditions. As a result, the aircraft rapidly safely. The full search and rescue organiza­ It was concluded that:- height and struck the ground about 45 feet lost height during the turn, the port wing tion was activated as soon as the pilot re­ inside the boundary fence and then slid stalled and the aircraft struck the ground. ported being unable to locate Cairns but (a) The cause of the accident was the in­ for approximately 100 feet before coming there were obvious difficulties in attempting ability of the pilot to determine his to rest. The aircraft sustained extensive The pilot states that when the wing to establish the position of an aircraft position after he had become lost at damage but neither of the two occupants dropped a "terrific effort" was made to commencing from an unknown position. To night whilst flying above cloud. was injured. raise the nose. Although it is seriously doubted that recovery could have been add to these difficulties the aircraft's fuel (b) The pilot became lost as a result of The investigation of the accident revealed was exhausted some 272 minutes after effected in the altitude available, the an error of judgment in attempting t hat the airbrake had been lowered. for pilot's action in attempting to raise the departure from Iron Range, whereas the taxying in the belief that it would help to pilot had notified an endurance of 300 to reach Cairns at night in unfavour­ nose when the aircraft was in a stalled able weather conditions in an aircraft stabilise the aircraft on the ground in the condition only made things worse. minutes, indicating that he had under­ existing gusty wind conditions. Subsequent­ estimated the fuel consumption of the air­ not equipped with adequate radio­ craft. navigation aids and because he failed ly, the pilot omitted to raise the airbrake The accident has been attributed to care­ to navigate the aircraft with the before take-off. lessness on the part of the pilot in failing The navigation facilities available in this degree of care demanded by the to carry out a thorough pre-take-off cockpit circumstances of the flight. The evidence indicates that the pilot aircraft were very limited and having re­ failed to realise that the airbrake was down gard to the terminal and route weathers check. passed to the aircraft it is considered that (c) A contributory cause of the accident the pilot made an error of judgment in was a lack of interchange of navigational information between Air overflying Cooktown and attempting to Norseman Encounters Soft Patch on New Guinea Strip and Overturns reach Cairns on this night. The terminal Traffic Control and the pilot in com­ forecast for Cairns indicated t hat there mand of t he aircraft, which precluded (18/ 2/ 2) would be complete cloud cover at various more effective navigation advice being levels below the aircraft's cruising altitude provided. NORSEMAN was being flown from The aircraft, being flown at the time by and it is apparent that navigation en-roub (d) The pilot's motives in endeavouring Wewak to Telefomin in New Guinea the pilot in command, touched down close by visual reference at 7,000 feet was to secure ·quickly, the best possible Awith a load of general cargo and one to the threshold and a little to the left of impossible after passing Cooktown. A satis­ medical care for the patient must be passenger. During the landing run at Tele­ the strip centre-line. It had run for some factory navigation plot could not be main­ highly commended, although his fomin the aircraft encountered a soft patch 1,800 feet on the ground before the accident tained by the pilot in this aircraft and the actions were not in the best interests into which the main wheels sank to the occurred. The pilot was familiar with the radio compass was of a type which could of safety. axles and the aircraft overturned and was strip, the type of aircraft and operating not be expected to provide a reliable indica­ extensively damaged. Although th8 pilot conditions in New Guinea and an examina­ tion except at very short range. In these (e) Adequate instructions relating to the in command escaped uninjured, the pilot tion of the aircraft did not reveal any circumstances thei·e were very substantial conduct of urgent medical flights in under instruction and the passenger were defects which might have contributed to hazards in attempting to r each Cairns at darkness or in unfavourable weather bot h injured. the accident.

20 21 The soft patch on the strip was in the would have revealed this condition before Fatal Spin In DH.82 nature of a drainage "soak" but its presence it became dangerous to aircraft. Action was not easily discernible to the eye either could then have been taken to effect repairs (18/2/3) from the air or on the ground. Although or· to warn pilots. N the late afternoon at Moorabbin Aero­ carried out. Even with deliberate intent he there had been some rain at Telefomin dur­ It was concluded therefore that- drome, Victoria, a private pilot took-off found it very difficult, in this test, to enter ing the preceding 48 hours the remainder I in a DH.82, with a young student pilot a spin off a steep turn by misuse of of the strip was quite firm and suitable for (a) The accident was due to the failure as passenger, for one hour of general flying controls. operations. For these reasons it was con­ of the owners of the Telefomin air­ practice. Some fifteen minutes later it was sidered that the pilot could not be criticized strip to maintain the airstrip at a seen by a number of eyewitnesses a few The pilot stated that the aircraft was for failing to avoid the soft ground. satisfactory standard for aircraft miles north-west of Dandenong to enter a behaving normally prior to the spin and a TeleJ'omin airstrip is owned and main­ operations; and spin which continued until it struck the thorough examination of the wreckage did tained by the New Guinea Administration (b) The deterioration of the airstrip ground. The aircraft crashed into the yard not reveal any evidence of defects which and, although the softening of this area which resulted in this accident was of a house and was extensively damaged. might have existed before impact. would probably have been gradual, it is probably not readily apparent to pilots ., The passenger in the front cockpit was In view of the standard of flying dis­ considered that proper strip inspections from the cockpit of an aircraft. killed and the pilot sustained minor injuries . played by the pilot, the known difficulty of The occupant of the house and another making this type aircraft spin without the person were conversing in the yard where mosi obvious mii>use of controls and the the aircraft crashed and both were struck statement of an eyewitness that the spin DH.83 Fox-Moth - Caught in Subsidence m Lee of by the aircraft. The householder received commenced after the aircraft had slowed very serious injuries and the other person down during straight and level · flight, the Mountain Range, New Guinea was struck a glancing blow, causing only pilot's statement could not be accepted minor injuries. without some reservation. Therefore, the (18/21/2) cause of the spin could not be conclusively After the accident the pilot stated that established from the available evidence. the spin was entered inadvertently whilst DH.83 Fox-Moth departed Port Moresby lose height. The pilot then attempte~ a at 0930 hours on a charter flight to turn to the right to fly out of the Gap and, executing a steep turn at an altitude of Similarly, the reason for the aircraft AKokoda in New Guinea carrying whilst still losing height in this turn, struck 3,800 feet and despite the repeated use of failing to recover from the spin could not general freezer cargo. The route involved a tree on the eastern side and crashed out the normal spin recovery procedures the be determined in view of the later estab­ a crossing of the Owen Stanley Ranges of control. aircraft continued spinning to the ground. lished ability of the pilot and the known (peaks to 13,000 feet), via the Kokoda Gap, Before the pilot flew again he was recovery characteristics of the aircraft which can be traversed at a minimum safe The pilot stated that th e aircraft was thoroughly examined in his techniques for type. Normally a DH.82 would be expected altitude of approximately 6500 feet. Whilst functioning normally right up to the time steep turns, spin recovery and general air­ to recover from a spin entered at this negotiating the Gap the aircraft struck a of the accident. However, the performance craft handling. His test performance was altitude even if the controls were released. tree and crashed onto a steep slope, clear capacity of the DH.83 does not provide any good and, in particular, his steep turn and To continue spinning it would have to be of trees, at an altitude of about 6500 feet. substantial safety margin when operating spin recovery techniques were correctly held in the spin. The aircraft was being flown by a conuner­ at the higher altitudes close to mountainous cial pilot who had considerable experience terrain. On this occasion the aircraft took DH.82 - Unauthorised Low Flying on this and other light aircraft in New some 65 minutes to climb to 7,40v feet and, Guinea. He escaped with minor injuries. at that altitude, there would be no reserve (18/ 1/ 1) The aircraft and its carg·o were destroyed climb performance to meet down draft PRIVATE PILOT licence holder took­ conditions. The flight path of the aircraft indicated by impact forces, and abandoned. ~he off in an aero club DH.82 from that the pilot did not see the power lines weather conditions in the area at the t11ne It was concluded that:- A Moorabbin aerodrome in the late or, at least, not until it was too late to take of the accident were scattered low cloud, afternoon. He was authorized to carry out any avoiding action. It was concluded overcast at 12,000 feet, visibility 40 miles (a) The accident was due to the failure a flight of 30 minutes duration in the that- and the wind was from the north-west at of the pilot to abandon the flight when approved training area and the aircraft about 15 knots. Thus the flight had to severe tuTbulence and strong sub­ carried a passenger in the front cockpit. (a) The cause of the accident was the in­ approach the ranges from the lee-side. sidence were encountered before the ability of the pilot, whilst engaged in aircraft reached a position where it Some 30 minutes later this aircraft was unauthorized low flying, to see OT The pilot has stated that after take-off could not be manoeuvred out of the seen by severnl ground witnesses flying at suspect the presence of high tension he climbed to an altitude of 7,400 feet in a Gap. a very low altit ude down a valley near wires; and position close to the southern approaches Lysterfield, Victoria, which is situated to the Gap before attempting to negotiate (b) A contributory cause was an error of several miles outside the approved general (b) a contributory cause was the pilot's it. During the approach to the Gap he judgment by the pilot in attempting training and low flying areas. The aircraft failure to observe the requirements of encountered moderate to severe turbulence to fly through the Gap at an altitude was seen to collide with power cables strung Air Navigation Regulation 133 (2) (b) with long periods of up and down drafts. which did not provide a safe margin across this valley, somersault and crash to by engaging in flight at a lower height As the aircraft reached the narrowest part of terrain clearance under the exist­ the ground. The aircraft was wTecked and than 500 feet outside an area of the Gap a strong down draft was both occupants received very serious in­ designated by the Director-General as encountered and the aircraft commenced to ing conditions. juries. a low fl ying area. 22 23 DH.82 Hits Tree Whilst Flying In Cloud Wackett Trainer Fatal Stall During Low Flying (18/ 1/ 8) (18/1/7) N annual carnival was held at Taree, members of an aero club ferried a occupants were killed on impact and the wo which might have contributed to the New South Wales, and included boat aircraft was destroyed by fire. DH.82 from Sydney to Goulburn, New accident. races on the Manning River. A former TSouth Wales, so that week-end flying A The pilot's flying experience amounted In view of the weather forecast provided resident of the town and holder of a private to some 200 hours of which 83 hours had training could be conducted at the Goulburn pilot licence set out from Newcastle in a aerodrome. Late on the Sunday afternoon, to the pilot and the nature of the terrain been flown in this type of aircraft. No they set out to return over the 90 odd to be traversed, there was quite a pro­ Wackett Trainer aircraft carrying a pas­ evidence of aircraft defect could be found bability at the outset that the flight would senger to attend the carnival and arrived and the load was well below the maximum miles to their base aerodrome in Sydney. over Taree at about 1045 hours. The pilot Before departing the pilot in command ob­ not get through and, indeed, this was ap­ permissible. The weather conditions were parently appreciated by the pilot. However, saw a motor boat being driven at speed on fine with good visibility and light winds. tained a weather forecast for the route the river and, apparently recognizing it as which indicated that the cloud base would it is considered that the pilot should not .. being driven by a friend, he descended and It was obvious that the pilot had engaged be approximately 1,500 feet above the have continued the flight beyond the point passed over it at a height somewhat less in low · flying in contravention of Air general level of the terrain with thunder­ at which he noticed lower cloud appearing than 100 feet. The aircraft then commenc­ Navigation Regulation 133 (2) and it is con­ storms in the area and he was informed ed a climbing turn to port through 300 sidered that the probable cause of the that, at the time of his enquiry, the cloud whilst cruising just below the base at 500 feet. It would have been sensible to have degrees with progressively steepening· bank accident was loss of control due to poor base at Bankstown was 800 feet. After dis­ and diminishing airspeed. It crashed in a technique on the part of the pilot in the cussing the situation with the senior opera­ abandoned the flight and returned to Goul­ steeply banked attitude still under power execution of a steep turn close to the tions officer at Sydney the pilot decided to burn at this point but he persisted in try­ onto r iver flats and burst into flames. Both ground. "give it a go" and lodged the appropriate ing to get through until he could -not even flight details. make a turn without entering cloud. Once The aircraft departed Goulourn at 1615 the aircraft had entered cloud in these DH.82 Strikes Tree on Approach at Maylands, Western Australia hours and levelled out at 500 feet following circumstances then the accident which .fol­ the main southern railway line to Sydney. lowed had become a distinct probability in (18/ 3/ 2) This cruising level was only 200 feet below view of the limited experience of the pilot. the cloud base, and some 25 minutes after DH.82 owned by the Department of did not hold a pilot's licence and the dual departure some lower patches of cloud ap­ From the evidence it was concluded Civil Aviation was engaged on local fly­ controls had not been removed from that ing in the Perth area and at about 1050 cockpit as is required by the Air Navigation peared on the track and the aircraft that:- A descended to pass under them. The pilot hours an approach was made into the south­ Regulations, There was no evidence of any then observed even lower cloud moving in (a) The pilot complied with the Depart­ west to land on Maylands aerodrome. Dur­ defect or malfunctioning in the aircraft ing the approach the aircraft struck the top from the north and he decided to return to ment's requirements for pre-flight which might have contributed to the Goulburn. Just as he completed a turn to of a tree near the aerodrome boundary, accident. the left onto the reciprocal track the air­ briefing and notification and, having knocked over a boundary fence post, craft entered cloud and the pilot regard to the information provided wrecked the undercarriage on striking a Although the lowest clear approach path endeavoured to hold the aircraft on an even levee bank just inside the boundary and to the aerodrome from this direction does to the pilot, the flight was properly not meet the general standards of the keel whilst descending slowly to regain commenced. slithered to a halt on the aerodrome proper in an upright position. The two occupants Department and is steeper than the normal visual reference. Before this could be ob­ powered approach angle for a DH.82, these tained the port wing struck a tree and the (b) The cause of the accident was an of the aircraft were not injured, but the aircraft swung violently to the right, aircraft sustained major damage. circumstances were well known to the pilot. error of judgment by the pilot in From the evidence it was concluded that struck another tree and crashed into a attempting ·to continue the flight in The aircraft was being flown by a depart­ small clearing. the accident was due to the failure of the such conditions of weather that visual mental officer who held a private licence and pilot to take sufficient care to ensure that whose experience amounted to some 1,300 The accident occurred less than a mile flight could not be maintained. the appr oach was made clear of all from the town of Wingello which is on the hours. The passenger in the front cockpit obstructions. railway line and 2,200 feet above sea level. (c) The pilot's error of judgment led him The aircraft was substantially damaged but into flight conditions which demanded the two occupants escaped with only minor a skill beyond the limits of his ex­ Wackett Trainer - Major Structural Failure In The Air injuries. perience and ability. (18/ 1/ 12) The flying experiences of both the (d) The pilot probably flew the aircraft at occupants were similar, amounting to some a lower height than 500 feet above WO student pilots left Ararat aero­ ham at an altitude between 2,000 and 110 hours, most of which had been obtained terrain without unavoidable cause drome, Victoria, on a local training 2,500 feet, it was obser ved by a number on DH.82. They both held valid private T fl ight in a Wackett Trainer aircraft of eyewitnesses on the ground to commence licences. There was no evidence of any contrary to the provisions of Air and, some 35 minutes later, when the air­ a gentle level t urn to starboard. Almost defect or malfunctioning in the aircraft Navigation Regulation 133(2) (b). craft was almost over the town of Streat- immediately the port wing was seen to be-

24 25 come detached from the aircraft. The approximately one month prior to the be i·eported so that the proper inspections lower boom at station 32 port which aircraft struck the ground ! mile from accident. Here again the repair work had can be made. It is interesting to note that resulted in abnormal loads being placed Streatham and the port wing landed a been incorrectly designed and poorly carr ied in an inspection following a heavy landing on the other members of the rear- further -! mile away. The main wreckage out (see photograph reproduced on page which occurred in another Wackett sub­ with consequent failure under normal burst into flames and was destroyed. Both 27). It was apparent that at some time sequent to t his accident a very similar oper ating loads. The inevitable failure occupants of the aircraft were killed on prior to the accident the lower boom of failure of the spar web was found. of the rear-spar with the boom discon­ impact. the rear spar had separated at the splice From t he evidence relating to this tinuous due to the ineffective splice was and consequently the bending stresses in accident it was concluded that:- probably hastened by a heavy landing The· pilot authorized to fly the aircraft the spar were being borne only by the three days prior to the accident . had some 62 hours flying experience and plywood web and upper boom. In such 1. The port wing parted from the aircraft 3. The splice in the rear-spar lower boom he had qualified for, but had not obtained, circumstances a structural failure in this following the struct ural failure of the at station 32 port, which was carried his private pilot's licence. The other spar even under normal flight loads would rear-spar under normal operating loads. out in March, 1951, did not conform with occupant of the aircraft, who was carri~d be almost inevitable. 2. The failur e of the rear-spar was due to the repair method given in t he aircraft as a passenger in contravent10n of Air either- manufacturer's overhaul and r epair Navigation Regulation 52(9), also held a It could not be conclusively established 2.1-A heavy landing three days prior manual, as certified in the airframe log student pilot's licence and had 54 hours of at what point in the history of the air­ to the accident which cracked the port book. flying experience. The aircraft was loaded craft's operating life this boom had failed. rear-spar near a splice in t he lower 4. Damage, found in December, 1953, to within permissible limits and the weather It is quite possible that the crack in the boom at station 32. This crack and the the port wing of the aircraft included at the time of the accident was fine, with spar web, which had been detected and re­ final failure of the rear-spar was made a crack in the rear-spar boom at station very little cloud, unlimited visibility and paired previously may have been the result easier by the separation of a badly 32 port and was probably due to a heavy a north-westerly wind was blowing at of this lower boom separating at the splice designed and poorly executed splice in landing or severe ground loop. 30-40 m.p.h. at that time. However a number of the lower boom at station 32 5. The repair to the crack in the i·ear-spar Earlier in the day of the accident the eng·ineers who inspected the area then did or web, whilst effective in t ransferring aircraft had been inspected by a licensed not notice any such boom failure. Then 2.2-Separation of a badly designed and loads across th e crack, was poorly engineer and passed as serviceable for again, during training operations three days poorly executed splice in the rear-spar executed. prior to the accident, the aircraft was sub­ flight, and durin~· the morning another jected to a heavy landing and, although student pilot had flown it for one hour on ~1 general flying training. The aircraft, which it was then inspected, it is unlikely that : was built in 1942, had flown 1,204 hours a boom failure could be visually detected in ' ' ~ 1 since new, 216 hours since the last complete such an inspection and it may have been overhaul, and 40 hours since the last in­ present at this time. It is also possible spection for a certificate of safety. that the final boom and web failure occurred during the flight on which the accident I An examination of the wreckage revealed occurred as a result of t he considerable that the port wing had failed at the root, reduction in ·strength of the spar arising folding upwards and to the rear. As it out of the poor workmanship in repairs, and failed the port , with pieces of the general reduction in strength from glue the upper skin, fell away separately and and timber deterioration. However, it is as the port wing came off the aircraft it considered that the inferior repair work­ apparently struck the top of the rudder manship was a prime factor leading to the and dislodged the fin which floated to the failure of the spar. 1 ground near t he port wing. As a result of this accident action was An examination of the detached port taken against the licence privileges of two wing revealed that the initial failure had maintenance engineers. A number of other ·I occurred in the rear spar and, probably, similar type aircraft were inspected and at a point where the lower boom of this similar faults rectified. The attention of I spar had been spliced some three years all engineers licensed in the relevant cate­ previously. It was obvious that this splice, gories was directed to the proper methods which had separated, had not been designed and standards of repair work. Revised in accordance with the repair and overhaul orders were issued calling for the close in­ j manual and· the standard of workmanship spection of W ackett Trainer aircraft after was poor. The splice stiffener block was heavy landings and it is in this respect that quite ineffective and the glueing of the all pilots flying these aircraft can assist Section of p or t wing rear spar showing splice faces was such as to be only partly towards their own protection. It is likely (a) separated splice in the lower boom (bottom effective. The plywood web of the spar had that damage caused by previous heavy centre) and the poor standard of glueing in its also failed and this was very close to a landings played a large part in the final vicinity (b) effectiveness of splice stiff ener lost similar failure which had previously failure of the wing in this accident and, by sectionalization between spar ribs (c) loca­ occur-red and had been repaired by patching, for obvious reasons, these landings should tion of previous crack in plywood w eb (bottom left) and (d) fin al b reak in plywood web (r ight). 26 27 Unsafe Separation On A Controlled Air Route (1746/53) PART IV WO DC.4s departed Melbourne for speed because of turbulence and the pilot INCIDENT REPORTS Sydney, via the direct route, with 20 notified an E.T.A. Marulan devised simply T minutes separation at Melbourne. Both by the addition of the flight planned time pilots elected to cruise at the same altitude interval to his incorrect Canberra reporting and, on flight plan times, the succeeding time. This, of course, took no account of Door Warnings In Pressurized Aircraft aircraft would make up four minutes on the longer route, reduced airspeed, greater (1618/54) the leading aircraft at Sydney. Minimum head wind component or the incorrect posi­ safe longitudinal separation on this route is tion report, and led the air traffic controller 10 minutes and on the position reports at to believe that the aircraft was complying HEN ready for departure the door The decision to proceed with the flight the Murray River the separation was re­ with the route instructions he had issued. warning light in the cockpit of a and pressurize was based on · the assu,mp­ duced to 17 minutes. WConvair 240 indicated that a door was tion that the warning system was faulty. Meanwhile, the following aircraft had not not locked. The despatch officer checked Gunnery exercises in the Canberra area deviated from the normal route and had the belly compartment doors and, at the It appears that this assumption was had been notified by N otam and Sydney dictated, primarily, by the flickering be­ notified an E.T.A. Marulan 17 minutes later same time, the first officer checked the A.T.C. issued an instruction to the leading than the leading aircraft. The two aircraft forward upper cargo compartment door. haviour of the warning light when the rear aircraft to track over 2CY broadcast reported at Marulan within two minutes of The light remained on and the first officer door and ramp were being checked and on station (i.e. 6 miles W.N.W. of Canberra) each other at the same altitude. went aft and lowered and raised the pas­ a visual check of the latch bolts. to avoid these exercises. The firing was senger ramp and also checked the rni:ir cancelled because of weather before the The investigation revealed that the pilot loading door. He reported to the captam It seems improbable that the flickering following aircraft reached Murray River o.i: the leading aircraft was not aware of and no such diversion was required of this that the loading door latches were visually of the warning light was associated with the route instructions issued and in turn checked. The captain has stated that, dur­ aircraft. the air traffic controller was completely ing the latter checks, the warning light engagement of the latches. The micro unaware of the actual diversion route switch is located in the door frame and For reasons, which cannot now be deter­ flickered but remained on and, as all doors mined, the pilot of the leading aircraft did flown. Certainly, every effort must be made had been checked, he assumed that a micro is tripped by a latch bolt during the final not receive or understand the A.T.C. by air traffic controllers to ensure that switch was faulty and decided to proceed 3/16" of movement. If the bolt went in instruction regarding his diversion route their instructions are received and under­ with the flight. far enough to momentarily trip the switch and this aircraft avoided Canberra by some stood, but, it is considered that this in­ cident would still have been avoided if the About seven minutes after take-off a it should have been safely engaged. 25 miles to the south-east. The pilot rn­ hostess reported that there was a pressure pilot of the leading aircraft had notified ported his position as "Canberra", when in A.T.C. of the nature of his diversion from leak from the rear loading door, whereupon, A visual inspection of the bolts is not fact, he had only intercepted the south­ the first officer inspected the door and eastern aural leg of the Canberra V.A.R. the normal rnute, or had complied with promptly advised the captain that the latch always conclusive evidence that they are at some 25 miles from Canberra. The standard position reporting procedures, or bolts were only just holding, although the safely engaged because in this installation ambiguity of this report (see AIP/RAC had re-calculated an E.T.A. for Marulan door handle was in the fully locked posi­ they can only be viewed across the gap be­ 1-9-3) was not queried by the air traffic in the light of the changed route and tion. Betore returning to the cockpit he tween the door edge and the door frame controller who assumed that the report was ground speed. Similarly, the air traffic con­ { troller should have insisted upon the Can­ warned the hostesses to keep a safe distance and thus a safe depth of engagement can­ "over 2CY" broadcast station. from the door and to keep passengers berra position report containing all the seated. Pressurization was dumped and the not be verified by this means. The leading aircraft then turned towards information re.quired by the Aeronautical aircraft returned to the departure point. Marulan into an 80 knot wind, reduced air- Information Publication. From checks carried out, the pilot con­ Examination of the door locking cluded that the warning system was faulty, mechanism showed that an actuating link­ but subsequent events proved that his Low Visibility Approaches at Nadi, Fiji age had been bent with the result that the analysis was incolTect. This incident shows effective length of the connection to the (6/855/15) latches had been shortened and, when the that the safest way to treat such a warning door handle was in the locked position, the is to believe it until the defective com­ CONSTELLATION 1049 aircraft by reference to the twin locator aids aligned latch bolts were not fully home in the door ponent of the warning system is located. arrived over Nadi Airport, Fiji, on 8th with the r unway but, although the aircraft frame housings. It would be impossible to predict all the AMarch, 1955, at 1210 hours with 210 broke cloud at 800 feet, the pilot was unable It is probable that the door locking combinations of faults and symptoms for minutes remaining endurance at holding to locate the runway and carried out the handle had been forced towards the locked the guidance of a pilot in analysing mal­ power. The weather at this time consisted missed approach procedure returning to 6,000 feet, the stipulated lowest holding position at some time when the door had functioning of the equipment and therefore of heavy showers passing over the field re­ been partially closed and with the latch ducing the visibility to one mile in some altitude. the safe rule is-"If the door warning light directions with a maximum of three miles. The visibility

30 31 . \

Dubbo and, in these circumstances, weather which are notoriously difficult to their action was reasonable having forecast. The dispersal of fog certainly falls regard to the safety of the aircraft. within this category. Then again, the con­ sideration of forecast weather against ob­ Referring to (c) above it was noted that served weather separated by a shor t inter­ the written instructions to A.T.C. officers val of time may also raise some doubts required that any diversion action by him regarding the accuracy of the forecast. must be based upon forecast weather con­ ditions or where doubt exists as to the ful­ Recognizing these uncertainties, parti­ filment of the forecast he must inform · the cularly as underlined by this incident, it pilot of the circumstances giving rise to was decided to allow to the officer provid­ this doubt. Since the terminal forecasts ing operational control, greater freedom to for both Sydney and Dubbo indicated that recommend or require aircraft to carry ad­ conditions would be above minima on ditional fuel reserves whenever some doubt arrival of the aircraft, the A.T.C. officer exists concerning the accuracy of the had no authority to divert the aircraft and weather forecast. Naturally this officer, in his action in keeping the pilot informed of the exercise of this discretion, will only re­ the weather development at both airports commend or require action which will in­ was consistent with his own personal doubts crease the safety assurance but he must and his instructions. endeavour to strike a nice balance between safety and the economy of operations. The Despite the conclusions described in (a), new provisions are described in paragraphs (b) and (c) above, the fact remained that 10.2 and 16.1 of AIP/ RAC 1-7. an aircraft had been caught in a most un­ safe situation. On considering how this It is anticipated that, by close co-opera­ might be avoided in the future, the instruc­ tion between air traffic controllers and tions to A.T.C. officers providing opera­ pilots, pooling infoimation and exchanging tional control were examined. These in· ideas, the potential dangers highlighted in structions appeared to place greater re­ this incident can be avoided and if, in the liance upon the fulfilment of a weather forecast than experience had justified or future, this prevents an accident it is no even the forecaster himself would claim to more than we can ask of the incident be due. There are many conditions of reporting system.