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COMMONWEALTH OF AUSTRALIA I DEPARTMENT OF CIVIL AVl1\TION

AVI A TION SAFETY DIGESlr

No. 7

SEPTEMBER, 1956

Prepared by the Division of Published by Authority Printed by McBean Bros., 48 Rankins Road, Kensington. Accident Investigation and Analysis of the Director-General CONTENTS

Page PART I-AVIATION NEWS AND VIEWS Misreading the Altimeter . 3

PART II-OVERSEAS ACCIDENTS DC-4 Fire in Flight ...... 5 DC-4 Ditching between Honolulu and Wake Island 6 Approach Accident, DC-6B, San Francisco Bay, California ...... 8

PART Ill-AUSTRALIAN ACCIDENTS Accident to DC-3 at Bourke, N.S.W. 10 I Accident to DC-3 on Instrument Approach to Cam- bridge (Hobart) Aerodrome 15 Take-off Accident near Stannum, N.S.W. 22 Helicopter Accident near Morehead, New Guinea 23 Collision with High Tension Wires . . 23 DH-82 Mid-Air Collision near Werribee, Victoria 24 Fatal Stall in DH-82 . . 25 Nose Heavy Norseman, New Guinea . 26 Proctor Lost in Cloud 26 DH -82 Take-off Accident . 27 Mid-Air Collision at Narromine, N.S.W. 2 7

PART IV-INCIDENT REPORTS Near Miss during l.F.R. Descent, Rome 29 The Need for Vigi lance in the Control Zone 29 V.F.R. and "Visual" Approaches . 30 Where you can assist AT.C...... 31 • PART I

AVIATION NEWS AND VIEWS

Quiz Session pilots and non-pilot college students in r ead­ ing the 3-pointer altimeter. These persons Take a pencil, note the time, turn to page were allowed approximately 7 seconds for 32 and underneath each dial write the alti­ each reading. The types of errors, and the meter reading and then note the time you frequency of occurrence expressed as a per~ have taken to complete all readings. Check centage of the total readings, uncovered in your readings against those given on page 4. this analysis were- Now, perhaps, you will be interested to read the article which follows. (a) Reading to nearest numeral instead of lower adjacent numeral (reading 13,960 as 14,960 because of failure to consider the more sensitive pointer) Misreading the Altimeter -pilots 4.4 per cent, non-pilots 3.7 per cent. N accident report in this Digest con­ (b) Reading to the lower adjacent num­ cludes that a very experienced pilot eral when the nearest numeral is A probably misread the altimeter during correct (reading 28,020 as 27,020 an instrument approach. Although most because of failure to consider the more pilots are aware that the conventional sensi­ sensitive pointer)-pilots 0.3 per tive altimeter with three pointers has certain cent, non-pilots 2.3 per cent. inherent readability limitations, the high probability of misreading it is not generally (c) Displacement of digit in number appreciated. But only careless pilots would series (reading 16,080 as 10,680 be­ misread their altimeter, you think. Tests cause of interchange of digit with indicate that careful pilots also misread this adjacent zero )- pilots 4.0 per cent., instrument. non-pilots 5.5 per cent. In 1947, the United States Air Forces Aero (d) Misreading of scale or numeral (read­ Medical Laboratory analysed 270 errors ing 34,640 as 34,620) because of made by pilots in reading and interpreting erroneous value assigned to scale instruments. This analysis revealed, inter divisions)- pilots 5.8 per cent., non­ alia, that one of the most common errors was pilots 7.1 per cent. in int erpr eting multiple revolution instru­ (e) Omission of one pointer (reading ments such as the sensitive altimeter. The 10,700 as 700 because of failure to altimeter was misread more frequently than read 10,000 ft. pointer)-pilots 1.7 any other instrument and by far the most per cent., non-pilots 1.3 per cent. common error was that of reading the altitude exactly 1,000 feet too high. This (f) Pointer exchange (reading '25,420 as analysis also found that instrument reading 52,420 because of interchange of errors are not confined to any single class or 10,000 ft. and 1,000 ft. pointers)­ group of pilots. In these tests 97 pilots made pilots 0.3 per cent., non-pilots 2.3 per 12 readings each from conventional sensitive cent. altimeters and of the total of 1,164 readings 11.7 per cent. were in error by 1,000 feet or (g) Repetition of reading on one pointer (reading 28,020 as 28,820 because of more. repetition of 1,000 ft. pointer reading) In the following year the U.S.A.F. Aero - pilots 1.0 per cent., non-pilots 0.8 Medical Laboratory examined a number of per cent.

3 These errors are attributed to the fact that are read in digits through a window in the an exact numerical value is obtained from dial. An improved presentation of the baro­ data presented by a combination of pointers metric scale is also incorporated which PART II on a single dial. That is, the 3-pointer alti­ f eatu res a four digit type counter. Another meter by virtue of its method of presenta­ type of altimeter which is designed to tion affords opportunities for errors. The overcome the most sel'ious error in read­ most serious (hazardous) of these errors is ing the 3-pointer altimeter, i.e., reading OVERSEAS ACCIDENTS that referred to at (a), i.e. reading too high the 1,000 pointer to the nearest numeral, by one revolution of the sensitive pointer. is one in which the 1,000 pointer i·emains This error is demonstrated at F ig. 2, page pointing at the numeral indicating the 32, where the 1,000 ft. pointer is pointing to thousands of feet until the altitude changes 4 on the scale, but to read the setting correctly 1,000 feet when it jumps to the next appro­ DC.4 Fire in Flight it must be read as 3 or 3,000 feet. The priate numeral. An altimeter with one error comes from reading the 1,000 ft. pointer and a logarithmic scale, which it is pointer to the nearest numeral, whereas it claimed will considerably reduce the in­ (This su11irnary is based on the report of should be read to the next lowest number. cidence of reading errors, is currently being the Civil Aeronautics Board, U.S.A.) (18/ 27/ 43) evaluated in Canada and present indications The majority of cases of misreading of the are that it would be comparatively cheap to N 15th June, 1954, at 0320 hours a fire was seen to momentarily die down but altimeter have occurred during instrument produce. DC.4 made an emergency landing off the almost immediately to flare up again. descents when the pilot has been concentrat­ Orunway at Gag-e Airport, Okla­ ing on flight attitude instruments, radio The Department is currently examining homa. The emergency landing was made At approximately 0312 while the captain conversation and instrument procedures with the available improved types of altimeters because of an uncontrollable fire in the was performing these duties the first officer the result that the altimeter only gets a with a view to their suitability as replace­ number 3 engine nacelle. There were no called Gage and advised that the number glance. From studies of pilots' eye move­ ment for the 3-pointei· altimeter. REMEM­ injuries to the passengers or crew, but the 3 engine was on fire and that its propeller ments during instrument flying it is known BER, until the present type of 3iltimeter is aircraft was destroyed by fire. had been feathered. The Gage communicator that pilots spend an average of 4/lOths of replaced, the greatest danger is in reading immediately turned on the airport runway a second each time they read the altimeter this altimeter too high by 1,000 feet when lights for the north-south runway. There under these conditions. This is very short letting down in instrument conditions. THE FLIGHT were no other radio contacts with the flight. by comparison with the average time taken The aircraft was engaged on a flight from The captain, unable to extinguish the fire, in the above tests, 7 seconds per reading. Kansas City, Missouri to Burbank, Cali­ began a left descending turn toward the QUIZ ANSWERS: fornia. The flight was routine until, when airport. During this tum the number 3 As a result of the studies of errors in read­ in the vicinity of Gage, Oklahoma, the cap­ engine fell from the aircraft, at which time ing altitude, various aviation authorities 1 16,080 tain was requested to climb and maintain a complete failure of the electrical system and instrument manufacturers throughout 2 13,960 6,000 feet. Shortly after, the stewardess was experienced. The captain testified that the world have been engaged for some time 3 13,330 entered the cockpit and told the pilots that thrnughout the approach he was unable to in developing altimeters with improved pre­ 4 10,700 she had observed sparks trailing from see the runway lights on the airport, and, sentation. Quite a number of different types 5 84,640 number 3 engine. A check by the first officer not being able to use the aircraft landing of altimeters have now been developed and 6 25,420 failed to find anything amiss, and the lights, he headed in the general direction 6f are available for installation. 7 28,020 stewardess returned to the cabin. the airport beacon. Throughout the latter 8 1,100 stages of descent the first officer used a flash One type that appears to overcome most 9 11,000 Some two or three minutes later, when light so that he could observe and call out of the problems is the counter type. It is 10 11,100 the aircraft was at an altitude of 5,500 feet altimeter and airspeed readings. As the air­ comparable in size and weight with the pre­ and in the vicinity of Gage, the zone 2 fire craft neared the ground the fire illuminated sent altimeter and has only one pointer One mistake is ·One too many and two warning light of the number 3 engine came the surface, permitting the captain to see mistakes could be fatal. reading in hundreds of feet. The thousands on. As soon as this w~s observed the first the ground and land the aircraft safely. officer went to the cabin to make a visual After rolling a considerable distance the check. He returned a few seconds later and right main landing gear collapsed. When reported there was a fire in the number 3 the aircraft came to a stop all passengers engine. The captain immediately returned were quickly evacuated. Fire eventually the aircraft to level flight and feathered the destroyed the aircraft. number 3 propeller. The fire-wall shut-off valve was then pulled, the C02 selector set INVESTIGATION • for the number 3 engine and the first bank of C02 bottles was discharged. As this ap­ Investigation conducted at the scene of the plication of carbon dioxide did not appear to accident disclosed that the aircraft first con­ put the fire out the engine's cowl flaps were tacted the ground on a heading of 110° about closed and the second bank of C02 bottles 900 feet to the left of the runway and 1,000 was discharged. Following this action the feet inside the airport boundary. After

4 5 rolling approximately 1,100 feet the r ight shaft and armature support tube. Approxi­ THE FLIGHT During the oper ation No. 2 engine stopped main landing gear collapsed because of fire mately ± of t he circumference of the for­ and its fuel pressure went to zero. Each fuel damage and the aircraft then skidded side­ wal'Cl and rear edges of the bear ing groove The aircr aft carrying cargo only was on selector was then checked for main tank ways to the right, stopping 1,800 feet from was cut, distorted, and rolled. The generator a flight from California, U.S.A. to Tokyo, position and t hey were found to be so posi­ the fast ground contact point. The captain drive shaft was broken just aft of t he clutch Japan, with scheduled refuelling stops at tioned with crossf eed valves off and main ordered an immediate evacuation of the assembly. The shear section of the shaft, Honolulu and Wake Island. The aircraft de­ boost pumps on. The captain then moved aircraft, which was done quickly and in an designed to fail under excessive loads, was parted Honolulu on an I.F .R. flight plan to the crossfeed controls to the "all engines to orderly manner through the main cabin and intact although bent one degree. The Wake Island, to maintain 8,000 f eet. crossfeed" position, which resulted in the pilot doors. Evacuation was accomplished armat ure and commutator components of Approximately six hours later the aircr aft fuel pressure of No. 4 engine fluctuating. The in an estimated lt minutes without serious the generator were severely scored, dis­ was t ransferred to Wake I sland A.R.T.C. crossfeed valves were then shut off and No. 4 injuries to any of the passengers or crew. torted and burned. The score marks on the and three minutes later an emergency was fuel pressure became immediately stabilized. The intense fire in the number 3 nacelle armature matched similar ones on the coils declar ed when the captain a dvised of t he loss The propellers of Nos. 1, 2 and 3 engines area continued to burn, spr eading pro­ and interpoles and were rotational in direc­ of power in three engines. The aircraft was continued to windmill with their respective gressively throughout the entire aircraft tion which indicated they were made while ditched during darkness. Neither Wake fuel selectors on main tanks, main boost with the exception of the lf'ft. wing and the armature was still tur ning. Island nor Honolulu radio was able to main­ pumps on, and crossfeeds off for a period he empennage. tain contact with the aircr aft and an exten­ considered sufficient for restarting. The ANALYSIS sive search was commenced. At 1318 hours engines did not start and their fuel pressur es The number 3 engine, which fell from the on the following day the captain and co­ aircraft, was found 11 miles north-west of Investigation and examination of the r emained at zero. The captain then feathered wreckage definitely indicated that the pilot were sighted and picked up by a surface Nos. 1, 2 and 3 pr opellers and used full the airport. As this engine was the area of vessel. power on No. 4 engine. origin of the fire, it was given exhaustive failure of a generator bearing was the initial examination. The nose case was demolished malfunction. This failure resulted in the During the descent at an airspeed of 135- by impact and cylinders 8, 9, 10, 11 and 12 generation of extreme frictional heat capable INVEST IGATION 140 knots, engines Nos. 1 and 2 were un­ of weakening and burning through adjacent feathered in separate attempts to restart; sever ely damaged by impact and fire. The On take-off from Honolulu all main fuel diffuser section and accessory case were fluid lines causing the release of inflammable both were unsuccessful. After refeathering fluids which wer e ignited. The fire pro­ tanks wer e full, and two outboard auxil­ and while attempting to r estart No. 3 engine, destroyed. Only portions of the accessories iar y tanks contained 130 gallons each. normally installed on the rear case wer e gressed so rapidly and became so intense the aircraft struck the water in a slightly recovered ; all had sustained fire damage. th.at available C02 was insufficient to When the main tanks wer e down to 400 nose-high attitude. Disassembly of the engine indicated that extinguish it. gallons, No. 1 and No. 2 engines were trans­ ther e was no failure or malfunction pr ior to The failure of t he generator drive shaft ferred to No. 2 auxiliary tank and Nos. 3 ANALYSIS impact. to shear at its designed shear section after and 4 engines to No. 3 auxiliary tank, with the crossfeed control positioned to each pair In order to investigate further the func­ the bearing failur e, permitted the generation tioning of the fuel system under the condi­ The generator for this engine, a Jack and of extreme friction heat and the r elease of of engines. When the f uel in the inboard Heintz Model JH 11300, type R-2, serial auxiliary tanks (Nos. 2 and 3) was down to tions reported by. the Captain, flight tests inflammable fluids with consequent intense wer e conducted in a DC.4 equipped with the number 772, was recovel:·ed. It was badly fire. 20 gallons in each tank the fuel selectors damaged by the intense fire and impact. were positioned to the outboard auxiliary same eight-tank fuel system for the pur pose Disassembly revealed that the inner and The loss of all electrical power at the time tanks (Nos. 1 and 4) . At that time ther e of duplicating the r eactions of the equipment outer races of the front bearings were badly the engine separated from the aircraft was were 40 gallons in No. 1 auxiliary tank to each combination of control positions re­ galled and distorted. Three accessory case most probably caused by a ground fault on supplying Nos. 1 and 2 engines and 100 gal­ por ted by the Captain. generator mounting studs were r ecovered. the power cables dur ing the physical break­ lons in No. 4 auxiliary tank supplying Nos. The flight tests proved conclusively that if Two were 6! inches long and were bent up of the nacelle installation. 3 and 4 engines. Nos. 2 and 3 auxiliary tanks the Nos. 1, 2 and 3 propeller s had been about five degrees at the point where they PROBABLE CAUSE were empty as the selectors had been posi­ allowed to windmill with the fuel system and passed through the generator mounting tioned to t r ansfer the fuel remaining in the engine cont rols in the configur ation descr ibed flange. The third stud had failed in tension The Board determined that the probable inboar d auxiliar y tanks after switching to by the Captain, the engines would have r e­ and bending at approximately the same cause of this accident was a bearing failure use of the outboard auxiliary tanks. started. The conditions descr ibed in the of the number 3 engine generator causing place where t he others were bent. Only the Soon after No. 1 engine stopped and its Captain's statement wer e : ignition on; fuel inner race of the rear gener ator bearing extreme frictional neat and the release of selectors positioned on the main tanks for inflammable fluid which ignited in flight. fuel pressure dr opped to zero. The captain was found. It was still attached to the drive then moved the No. 2 and No. 3 fuel selectors each r espective engine; main tank boosts on ; , from off to the full forward position (No. 1 mixture auto-rich; crossfeeds off. DC-4 Ditching between Honolulu and Wake Island and No. 4 fuel selectors were alr eady in the While feat hering the three propeller s forward or auxiliary tank position) , mis­ would slow the r ate of descent, the action (This summary is based on the report of takenly thinking this was t he position for t he definitely removed any possibility of restart­ the Civil A eronautics Board, U.S .A .) (18/ 27/ 96) main tanks. He also shut off the crossfeeds. ing the engines while in that .condit ion. The The No. 3 engine t hen stopped and its fuel separate unfeathering of t he propeller s and N 24th September, 1955, at about 0641, one crew member went down with the sink­ pressure dropped to zero. The captain the starting attempts probably consumed a DC.4 ditched in the Pacific Ocean, ing aircr aft and two others subsequently realised his error and pulled all four selectors mor e time and altit ude than the original approximately 1,000 miles west of feathering may have gained. O drowned before the arrival of a rescue vessel to the centre or main tank position and Honolulu after a loss of power in thr ee moved the four mixt ure controls to t he auto­ The probability of simultaneous failure ·engines. 'Two of the crew of five sur vived, the following day. rich position. of three engine-driven fuel pumps is remote.

6 7 However, even with the three pumps inopera­ two engines to be opernted on one auxiliary 500 feet. In doing so, he may have lost error in estimate of altitude stems from the tive, full pressure would have built up tank clown to 20 gallons of fuel is considered visual reference to the surface both with fact that a nosed-up attit ude of the aircraft immediately, if the fuel selectors had been poor operating practice. respect to the lights on shore and to the causes a distant light or concentration of positioned on the main tanks, each containing surface of the water. As the waters of the lights to appear lower and the aircraft thus By reason of the positive results obtained Bay were reported as smooth, a condition higher . approximately 400 gallons, and an electric in the flight tests, it was concluded that the , boost had been used on these tanks. existed that made it extremely difficult if not Captain's and co-pilot's recollection of events impossible to judge distance above the water, Notwithstanding the points mentioned It is evident that if the remaining fuel occurring after the loss of power, as de­ especially as it was at night and no othe1· above, there remains the f act that the pilot (20 gallons each) in Nos. 2 and 3 auxiliary scribed in their statements, was incorrect as means of reference were available for visual had two altimeters in the cockpit. It was dis­ tanks had not been transferred, the loss of to action and/ or sequence. This absence of orientations. closed that prior to landing at San Francisco power would have not occurred when it did accurate recollection is understandable when the flight received and acknowledged the San consideration is given to the stress of the In this connection, t he third condition Fr ancisco barometric pressure of 29.90 even though the Nos. 2 and 3 fuel selectors enters the then existing situation. This is a were incorrectly positioned for an indefinite emergency and subsequent events after the inches. There was no appreciable change in ditching and before rescue. condition wherein an erroneous belief of an pressure between this time and the time of period after the loss of power on the three aircraft's altitude can occur when attempting departure from San Francisco when both engines. PROBABLE CAUSE to maintain orientation by means of visual airports reported the pressure at 29.89 The flight test also showed that even reference to distant lights. In this case the inches. Therefore, it can be concluded that though the fuel transfer was made and the The Board determined that the probable ·aircraft was approaching the shore some there was no possibility of erroneous alti­ three engines subsequently stopped, there cause of the accident was the loss of power five miles distant where there were numerous meter setting existing as a factor in the was more than sufficient time from the alti­ in three engines clue to incorrect fuel system lights. But the concentration of the much accident. tude of 8,000 feet to restart the engines. The management and faulty restarting methods stronger lights at the airport proper could - practice employed by the crew in allowing which resulted in the ditching of the aircraft. well cause that cluster of lights to appear as PROBABLE CAUSE a single foci, and thus cause a sensory illu­ It was considered that the probable cause sion, such as described by P . P . Cocquyt in of the accident was the pilot's action in con­ Approach Accident DC-68: San Francisco Bay, California his paper "The Sensory Illusion of Pilots". tinuing descent below the 500 feet prescribed (This summary is based on the 1·eport of Under such conditions a pilot believes that minimum altitude until the aircraft struck the Civil Aeronautics Board, U.S.A.) (18/ 27/ 5) he is higher than he really is, and so invites the water. A possible contributory cause to quick disaster if at an extremely low altitude, the aircraft striking the water was the sen­ T approximately 2308 hours on 20th water. The precise reason or reasons for the as was the case in this flight. Briefly, the sory illusion experienced by the pilot. April, 1953, a DC.6B aircraft crasherl pilot's action or lack of action in allowing A into San Francisco Bay, California. the aircraft to descend into the water is a The accident occurred whilst the aircraft was matter of conjecture. However, there were descending to enter the traffic pattern for several pertinent conditions and circum­ landing. Two of the ten occupants survived. stances that can be considered as contri­ The aircraft was demolished and sank. butory factors. These were the type of operation being conducted, the weather con­ ditions that existed over the Bay and the THE FLIGHT sensory illusions that can occur under cer­ The aircraft was on a fl ight from Los tain conditions. Angeles to Oakland, California with an inter­ The type of operation being conducted was mediate stop at San Francisco. The aircraft somewhat of a special nature wherein flights departed from San Francisco at 2305 and between the Oakland and San Francisco was cleared direct to Oakland Tower to re­ Airports, which are 10 nautical miles apart, main clear of clouds at a minimum altitude of 500 feet. Two minutes later the aircraft are permitted to fly at altitudes below the advised Oakland that it was on a clearance to minima normally prescribed for scheduled the Oakland Tower and requested clearance, airline operations and also below the normal which was granted, to enter the traffic Visual Flight Rule weather minima. This pattern. At approximately 2302 an orange has been authorized to expedite traffic be­ flash was observed in the direction of the tween these two airports in view of the short aircraft's flight path and subsequently the distance involved and the fact that such wreckage was located in San Francisco Bay. flights are made entirely within controlled airspace. • ANALYSIS It appears that in prnceeding over the Bay, the flight encountered a cloud condition From the testimony of the two survivors, lower than indicated from pre-flight reports it is apparent that the accident resulted from and that the pilot, endeavouring to stay the pilot's failure to maintain sufficient alti­ clear of clouds as r equired for this operation, tude to avoid contact of the aircraft with the descended below the minimum altitude of

8 9 from the engine just after ground contact From the examination of the wreckage it and came to rest 60 f eet short of the main was not possible to account for poor per­ wreckage. formance of the aircraft described by the crew. PART Ill The wreckage was located 3,200 yards from the end of the runway and 8 degrees to the right of its centreline. The surrounding ANALYSIS terrain is flat and sparsely covered with trees Calculations, and flight tests on a number AUSTRALIAN ACCIDENTS of an average height of 30 feet. of airline DC.3's, show that this aircraft should have climbed in the "clean" configu­ ration at 270 feet per minute with take-off INVESTIGATION power on one engine. Thus, the rate of climb should not have been marginal and any fac­ Accident to DC-3 at Bourke, N.S.W. The captain testified that after feathering tors affecting performance would need to the starboard propeller the aircraft would have been of appreciable magnitude for any (6/255/466) not climb but gradually decelerated and lost one of them alone to have accounted for the height, and when the speed had dropped to N 15th December, 1955, a DC.3 was engine. The captain, although not aware of loss of performance described. For instance, about 80 knots he decided to abandon the under the conditions prevailing at the time involved in an emergency landing fol­ these latter symptoms, heard the backfiring take-off. 0 lowing malfunctioning of the starboard and felt an uneven load on the rudder pedals; of take-off, a windmilling propeller would engine immediately after take-off · from from these symptoms he concluded that the The airframe was largely destroyed by reduce the rate of climb by about 150 feet per Bourke Aerodrome. The landing was carried engine had failed and as a result feathered fire. The outer wing sections and empennage minute, or an extended undercarriage by 132 out in a clearing in a sparsely timbered area the starboard propeller. were substantially intact and showed no feet per minute; combined, these two factors one and a half miles north-east of the aero­ evidence of pre-crash deformation or defect should result in a rate of descent of 12 feet drome. The three .crew members and ten A few seconds later the first officer saw which would cause or contribute to a loss of per minute. passengers escaped injury but the aircraft the starboard propeller had not stopped but performance. The aircraft's maintenance and Flight tests were undertaken to see if the was destroyed by fire. was rotating at an engine speed of some 600 overhaul records, and the comments of pilots behaviour of the starboard engine and pro­ to 700 r.p.m. and he could only distinguish who had flown the aircraft previously, did peller, subsequent to the captain's action to At the time of the accident the aircraft individual blades with difficulty. He con­ was being operated on a regular public trans­ not indicate any abnormal characteristics or stop this engine, could be reproduced, and if cluded that the propeller had not feathered deterioration in performance. Except for so, to observe the effect upon the performance -port flight which originated at Sydney and and so informed the captain, who instructed subsequently arrived at Bourke at 1321 engine surging on take-off at Mascot and of the aircraft. By leaving the mixture con-· him to press the feather button again. The Nyngan the crew testified that the aircraft trol in automatic rich and the throttle at hours'"' after an intermediate stop at Nyngan. button was pressed several times but each From Bourke the flight was scheduled to behaved normally prior to the take-off at either take-off or cruise power settings, the return to Sydney via Nyngan and Warren. time immediately returned to the normal Bourke, and that the indicated airspeeds for behaviour of the propeller, as described by position. On the captain's instructions the various phases of the flight were normal. the first officer, could be exactly reproduced first officer then held the button in for some THE CIRCUMSTANCES by pressing the feathering button only; the two or three seconds but, on releasing it, the It was established that the port propeller propeller feathered normally but continued During the take-off from Sydney the cap­ button again immediately returned to the was rotating, but not under any appreciable to rotate at about 500 r .p.m. under power tain noticed some slight surging of the normal position. The first officer was unable amount of power, when the aircraft landed. from the engine which vibrated excessively. engines and had difficulty synchronizing to detect any change in the propeller's con­ The damage to the starboard propeller To achieve any noticeable change in the be­ t hem during the climb. Surging was again dition and it continued to rotate at a constant showed that it was feathered and not rotat­ haviour of the propeller or engine the feather experienced during take-off at Nyngan, the speed accompanied by considerable vibration ing when the aircraft landed. No defects button had to be held in for at least four intermediate stop, but this disappeared on of the engine. At about this time the captain which would affect the aircraft's perform­ seconds when their speed of rotation the first reduction from take-off power. The decided to abandon the take-off. Eyewitnesses ance were found in the propellers. g-radually increased as the propeller un­ flight from Nyngan to Bourke was otherwise state that the aircraft did not climb much feathered. If the throttle or mixture con­ uneventful, the aircraft arriving there at after take-off before levelling out, ·and the1·e­ Although both engines were substantially damaged by fire it was found that the power trol was dosed whilst the propeller was 1321 hours; it was then loaded and refuelled after it flew just above the trees for about a rotating in the feathered position, the engine for the return flight. mile before descending from sight. At this sections had been in good condition with no stopped immediately. At about 1337 hours the aircraft was time the starboard propeller was rotating sign of mechanical failure. The only signifi­ taxied to the displaced threshold marks to­ slowly, and was seen to stop just before the cant defect was lead fouling of certain spark It is concluded that the fouled plugs ac­ wards the south-west end of Runway 5 and aircraft descended from their view. plugs. Apart from four, which were too counted for the backfiring and loss of power a take-off was immediately commenced into damaged to test, all plugs from the port reported in the starboard engine, and that The landing was effected in an area almost engine had acceptable electrode gaps and this engine did not fail completely, _other the north-east. The aircraft became airborne clear of trees but near the point of touch­ after an apparently normal take-off run, but these tested satisfactorily, except for one than perhaps momentarily, but because the down the starboard wing tip was sheared off from the rear position of No. 8 cylinder mixtur e control and throttle were not closed shortly after leaving the ground the star­ on a small tree. The aircraft maintained its board engine backfired and the first officer which had extensive deposits of metallic when the propeller was feathered the engine direction for 380 feet before colliding with lead on the insulator surfaces. This plug continued to operate with considerable vibra­ noticed a fluctuation of revolutions and mani­ a stump which caused it to slew violently to fold pressure and rough running of this showed almost complete shorting under test tion, due to the propeller rotating in the, the right and turn through about 180°. It as did three from the starboard engine which feathered position. It was established that * All times, based •on the 24-hour clock, are ex- came to rest 555 feet from the first point of were also fouled by metallic lead. the decrease in climb performance due to pressed in Eastern Standard Time. contact. The starboard propeller was torn 11 10 the propeller rotating in the feathered posi­ rich. These symptoms have been attributed Although the wreckage examination failed from severe detonation, necessitating tion was about 30 feet per minute; therefore, in the main to plugs misfiring due to lead to explain the loss of performance described an emergency landing. drag from this propeller was not, of itself, fouling. The reduction in cylinder head tem­ by the crew, there are a number of defects ( b) A partial loss of power on the port a factor necessitating the emergency landing. perature and pressure on reducing power detectable in a power check which could have engine due to moderate detonation re­ or using emergency rich accounts 'for the accounted for a substantial loss of power. sulting in a marginal climb perform­ Although both pilots stated that after the disappearance of these symptoms. Investigation into this aspect revealed con­ ance which through the captain's lack starboard engine failed the port engine was flicting views as to whether a proper power of experience and knowledge of single­ Of the four plugs from the port engine check was performed prior to this take-off. delivering full take-off power, this cannot "·hich could not be tested two were located engine operation and performance be regarded as conclusive. Prior to this acci­ The captain said that it was made whilst led him to abandon the take-off. in the same cylinder-No. 7. The companion taxying and during the turn from the taxi­ dent, a number of incidents had been re­ plug of the defective one in No. 8 cylinder ( c) The pilot abandoned the take-off in ported of backfiring and propeller surging in taxiing and during the turn from the taxi­ tested satisfactorily. way onto the runway. In view of the short the belief that it could not be con­ DC.3 aircraft with Pratt and Whitney R.1830 t inued safely after being informed installations. Almost invariably these symp­ If plug malfunctioning alone in the port time it would take to turn through 90° on to engine accounted for a marked deterioration the runway it seems that, at the most, only that the starboard propeller was wind­ toms were manifest only at take-off power milling and could not be feathered. and were frequently accompanied ·by high in performance it would be necessary for two a cursory power check was made. This is cylinder head temperatures. It is reported cylinders at least to be inoperative. There is contrary to good practice, and particularly If the aircraft would not accelerate or that these symptoms which did not always no evidence of this. The examination of the so on this occasion in view of the engine climb, as the crew claim, then it is clearly appear together, were nearly always elimi­ port engine indicates that its power output su!ging on previous take-offs, which the cap­ evident that there must have been a ver y nated by reducing to rated power or by may have been reduced about 20 horsepower tam reports. Although there is no ·evidence substanjial loss of power in the port engine, placing the mixture control in emergency due to the defective plug in No. 8 cylinder. of a substantial loss of power· in the port of the brder of-25 per cent. In these circum­ engine a power check performed in the way stances it would not be possible to continue the captain described would deprive the crew the take-off. However, no evidence of such of the opportunity of ensuring, so far as is a power loss could be found from any source; possible, that this engine was operating nor­ detonation of the necessary severity would mally immediately prior to· the take-off. have been accompanied by obvious sym_p­ Sco-Llcred Since this accident some aut~matic mix­ toms, such as rough running and backfiring, ture controls have gone out of adjustment which even if Il.ot observed by tlie pre­ in service in several DC.3's of the same com­ occupied crew, should have been noticed· bY' pany. The defect involved stretching of the the engineer in the cabin. automatic mixture control capsule thus alter­ On the other hand the ·possibility of the ing the setting of the metering needle to port engine being affected to some lesser which it is attached, causing a leaning of the extent by detonation is not so remote and mixture in the take-off power range. As the if the effect of this, together with that due carburettors are set on the rich side of best to the behaviour of the starboard propeller power at take-off this leaning of the mixture was such that the rate of climb was reduced tends to increase power in the take-off range. by 150 to 180 feet per minute, then the climb Nevertheless, at high ambient temperatures performance of the aircraft would have been this mixture leaning would be conducive to distinctly marginal and it would have been detonation resulting in a nett loss of power. necessary to fly it very carefully to gain If detonation, such as would reduce the height . Unless this was done the aircraft power output of the port engine to an extent would lose height. It is significant that the that the aircraft would not climb, had been captain did not check the airspeed when the occurring regularly there would have been engine failed and he had no particular speed evidence of it in the strip examination. The in mind at which to fly the aircraft; there­ engine, which had operated for some 600 fore, he was unable to make an appraisal of 5co-ltered -lirnlocr hours since overhaul, was in good condition the aircraft's performance. In these circum­ Jo' hu3h when stripped. Furthermore, a company stances, with his limited experience and engineer who was travelling as a passenger knowledge of flying t he DC.3 type on one in this aircraft and was seated on the port engine, his inclination might well have been side of the cabin, noticed no malfunctioning to abandon the take-off. Although this ex­ of the port engine, as would be apparent planation of the accident is considered to be with severe detonation, during this t ake-off. more probable than that outlined previously, there is no clear evidence of detonation to LOCALITY PLAN SHOWING LOCATION OF AIRCRAFT, After reviewing all the evidence it is con­ support it. PROBABLE FLIGHT PATH, ESTIMATED SPEEDS AND sidered that this accident could have occurred in one of three ways- The possibility that the captain abandoned T IMES, AND LOCATION OF WITNESSES. the take-off when he was informed that the '5F.__· --..,,.....L'f-.---..---,'5,i...1o_o· ..----'3~oo· ( a) Through a substantial loss of power starboard propeller was continuing to wind­ Scale o/ Fee£ on the port engine, probably resulting mill is considered to be the most reasonable

12 13 explanation for this accident. It is based on was felt for the aircraft . The aircraft aircraft without injmy; the aircraft was engine inoperative, the propeller feathered, the evidence of the first officer and two suddenly disappeared behind th e trees." destroyed by fire. the undercar riage and flaps retracted and ground eyewitnesses and is not in conflict 2. The aircraft was operating under valid the port engine at take-off power. This rate with the known facts, but the captain, The obser vations of this witness were con- cer tifi cates of air worthiness and registration, of climb is reduced by approximately 30 feet naturally enough, disputes it. However, in firmed by a companion who was with him at and a valid maintenance release. The two per minute when a propeller rotat es under contrast t-0 the captain's account of the cir­ the time. The area in which they saw the pilots were properly licensed for the duties power in the feathered position. ' cumstances, the important detail in the aircraft level out is about 8,000 feet from they were performing. 9. Although t he pilot in command claims the start of the take-off. Although the cap­ that he decided to abandon the t ake-off be­ original statement of the first officer sub­ h in denies abandoning the take-off shortly 3. The all-up-weight on departure, ap­ stantiates this explanation except only for cause, after his attempt to feather the star­ after the failure to stop the starboard pro­ proximately 24,092 lb., was within the maxi­ boar d propeller, the aircraft decelerated and the first officer's belief that the starboard mum imposed by the conditions obtaining at propeller did not feather. This belief was peller, the evidence of the first officer strong­ lost height, it is considered that the behaviour ly suggests that he may have done this. Had the t ime, and the centre-of-gravity was of the aircraft as described could not be at­ based on the appearance of the blades, which within the prescribed limits. he could only distinguish individually with he done so at the time indicated by the first tributed solely to mechanical malfunctioning, officer then the aircraft was in the area 4. The malfunctioning of the starboard including detonation. difficulty. As his observations accurately where it was seen to flatten out and fly for describe a propeller turning in the feathered engine was caused by the breakdown of a 10. Although no evidence of detonation in about a mile before descending from their number of spark plugs at take-off power position it is apparent that he misinterpreted view. the port engine could be obtained, it has not what he saw. apparently because of the "build up" of been possible to dismiss conclusively this The captain's experience of flying the DC.3 metallic lead on the plug insulator surfaces. possibility. The deter ioration in the per­ According to the first officer the take-off on one engine was confined to conditions un­ 5. Despite statements to the contrary by formance of the aircraft that would have was abandoned some twenty seconds after der which the aircraft had a positive and the pilot in command and the first officer, it resulted from this condition could have been action had been taken to feather the star­ clearly perceptible rate of climb. His limited is considered that the starboard pr opeller aggrnvated, if the aircraft was not handled board propeller. In this time with an other­ knowledge of the performance of this type feathered normally, but the propeller con­ so as to produce its optimum performance, to wise normal aircraft, assuming feathering ~r ith a windmilling propeller placed him in tinued to rotate under power because the an extent that would make an emergency started at 105 knots and that the optimum an awkward situation when he was informed pilot in command failed to take proper landing inevitable. speed of 90 knots was achieved and there­ that the starboard propeller had not feather­ feathering action in that he omitted to close 11. At the time of the accident the pilot­ after maintained, the maximum height ed. To continue, as he himself pointed out the throttle and mixture control. reached would have been approximately 250 in-command possessed an inadequate know­ in discussion, would necessitate running the 6. There is no evidence of any defect in ledge of the perfor mance of anq the tech­ feet. At the -0ptimum speed the nose-up atti­ port engine for an extended time at take-off the airframe or the port engine, except for nique for flying the DC.3 type with one tude would be quite pronounced. Eyewit­ power. He indicated that if under these one spark plug from No. 8 cylinder which engine inoperative. nesses' evidence indicates that there was circumstances it subsequently failed he might br oke down dur ing bench tests. nothing unusual in the attitude of the air­ then be committed to a landing in unsuitable 12. CAUSE: The probable cause of the craft and that there was no marked change terrain with disastrous results. Without a 7. The pilot in command decided to carry accident was that the pilot , having failed to in direction. It is apparent that the aircraft full knowledge of the behaviour of a DC.3 out an emer gency landing shortly after adopt the correct technique for asymmetr ic was not flown at optimum speed and thuR on one engine, and if, as there is good reason initiating action to stop the starboard engine flight following failure of the starboard the height reached at the end of the 20 to believe, the captain was not confident that and feather the propeller, because he believed engine on take-off, abandoned the "take-off in second period would have been substantially the aircraft would maintain height with the that the aircraft was not perfor ming the belief that it was not possible to remain less than the maximum of 250 feet. In this propeller windmilling, then there was no­ adequately on one engine for the take-off to airborne. regard the evidence of an eyewitness located alternative open to him but to abandon the be continued safely. · 13. In his handling of the situation fol­ a shor t distance from the aerodrome is sig­ take-off. 8. Flight tests of a number of airline lowing failure of the starboard engine the nificant. He stated that- Air Navigation Regulation 214 requires aircraft show that , under the conditions ob­ pilot was severely handicapped by his in­ taining at the time of this take-off the aver­ adequate knowledge of the performance of "My attention was drawn to the aircraft that an airline provides a training and check­ ing organization to ensure that its operating age DC.3 should have a .climb performance of and the technique for flying the DC.3 type by the spluttering of one of the en12;ines. 270 feet per minute with the starboard with one engine inoperative. I then observed the aircraft about three­ crews maintain their competency. Having quarter s of the way down the strin at a regard to this pilot's shortcomings it would height of approximately 50 feet but I did appear that this company might not have Accident to DC-3 on Instrument Approach to Cambridge (Hobart) Aerodrome not notice the airscrew. The aircraft was fully obser ved its obligations under this lost to sight behind the trees and when Regulation and that this factor may have (6/ 156/ 2) . contributed to the accident . next it came into view it was just over the DC. 3 freighter arrived over the Hobart The aircraft aclmowledged, but thereafter no end of the strip just above tree-top level CONCLUSIONS "Z" marker at 0322 hours on 12th Jan­ f ur ther communications were received from which would mean the aircraft was about Auary 1956, after an uneventful flight it. At 0548 hours aircraft wreckage and one 100 feet above the ground. At this time 1. On 15th December, 1955, at about 1340 from Melbourne. After holding in cloud at survivor, the captain, were sighted in the starboard airscrew was rotating ex­ hours a DC.3 was involved in an emer gency 4,000 feet for 11 minutes, the· aircraft was Frederick Henry Bay, seven miles south-east tremely slowly and the other engine ap­ landing following malfunctioning of the cleared for an instrument descent into Cam­ of Cambr idge Aerodrome. The captain was peared to be at full power. The aircraft starboard engine immediately after take-off bridge (Hobart) Aerodr ome. Appr oximately picked up approximately 25 minutes later was then obser ved to flatten off and main­ from Bourke Aerodrome, N.S.W. The air­ 5 minutes later the aircraft advised Hobar t and the body of the first officer was re­ tain altitude for about one mile, but as craft was landed in a small clearing 1t miles Air Traffic Control that the aerodr ome lig·hts covered later in the day. There wer e no other from my position the aircraft was just north-east of the aerodrome. The ten pas­ were in sight and it was then cleared to land. occupants in the aircraft. above the tree-tops considerable anxiety sengers and crew of three escaped from the 15 14 ACCIDENT TO OC3 AIRCRAFT NEAR CAM&RIDGE AERODROME, TASMANIA ON 12T" JANUARY, ICJ~G

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~ i- v.rt~col ~co l • twlco hari&o"tol s col• THE CIRCUMSTANCES south-east leg of the V.A.R. at an angle of An aerial search was commenced shortly quantity of refrigerant carried in all re­ about 30° (see plan on page 16). On passing after first light and a survivor, subsequently frigerators had been released into the cockpit The aircraft departed Melbourne Airport the "Z" marker outbound the descent was found to be the captain, was sighted at 0548 at the one time it would not have had any at 0109 homs on 12th January, 1956, for commenced at 500-600 feet per minute at 115 hours and was picked up by boat at approxi­ serious effects on the crew. Cambridge Aerodrome on a special freight knots with the undercarriage up. At an j mately 0620 hours, i.e., 2 hours 40 minutes (charter) flight with a crew of two. The altitude of 2,500 feet a procedure tum to after the accident. In the vicinity of the No evidence was found to suggest that the all-up-weight on departure was 26,200 lb. the right was commenced and the under­ position in which the captain had been flying controls were other than serviceable and the freight comprised 12 refrigerators carriage lowered. A rate of descent of 200- located, the body of the first officer was found at the moment of impact. It was established and 61 cases of tomatoes. The weather fore­ 300 feet per minute at 115 knots was main­ at approximately 1000 hours that the undercarriage was down and locked cast for Cambridge Aerodrome at the esti­ tained during· this tlll'n, which was completed on impact and that the flaps were up. The mated time of arrival, 0333 hours, was 8/8ths at an altitude of 2,000 feet, at which stage instrument panel was crushed and distorted strata cumulus cloud base 2,000 feet, 2/8ths the aircraft was again on the south-east leg ' SALVAGE OPERATIONS and a number of instruments was missing, in stratus cloud base 1,000 feet, drizzle, visi­ particular the mechanism of the captain's of the V.A.R. and heading for th.e "Z" The wreckage was located in a position 5! altimeter. The barometric scale of the first bility 4 miles and wind light and variable. marker. The captain states that during the miles from the Hobart D.M.E. on the south­ This weather necessitated provision being officer's altimeter was set to 1002 millibars. turn he "could dearly see large areas of east leg of the V.A.R. and approximately in An examination of the gyroscopic instru­ made for an alternate and on departure from water but no lights" and as the turn was the centre of Frederick Henry Bay. The Melbourne Airport the aircraft carried suf­ ments established that they were spinning completed "could see Seven Mile Beach but depth of water at this point was 50 feet. at the time of impact and as far as it was ficient fuel for the flight to Cambridge Aero­ could not see the aerodrome or aerodrome drome, holding for 26 minutes near Cam­ Salvage operations were commenced on possible to tell, there were no pre-crash de­ lights" nor was there "any cloud between fects in the pitot static system, the vacuum bridge and then diverting to Launceston, to my position and Seven Mile Beach, but to 13th January, 1956, the day after the acci­ arrive at Launceston with a reserve of 52 remain visual I continued to descend at 1,000 dent, with equipment and personnel provided system or any of the instruments available minutes. feet per minute". Shortly afterwards the by the Hobart Marine Board. All the major for examination. It was established from an components were recovered and these opera­ examination of the components of the auto­ En-route to Cambridge Aerodrome the air­ aerodrome lights were sighted and at an altitude of 1,000 feet he "trimmed the air­ tions were completed on 18th January, 1956. matic pilot that it was not in use at the time craft reported at the designated reporting of the accident. points on schedule, and arrived over the craft and adjusted power to maintain a rate Hobart "Z" marker at 0322 hours at an of descent from 200-300 feet · per minute INVESTIGATION There was no evidence of any pre-crash altitude of 5,000 feet. The Cambridge direct towards the end of the runway". At defects in the engines. The propeller blade this time, 0339 hours, the captain, who was The fuselage, with the port wing and tips of both propellers were bent backwards weather at this time was 5/8ths cloud at empennage attached, was found supported on 1,200-1,300 feet, 8/8ths cloud at 2,000-2,200 flying the aircraft and also operating the and it was established from the damage to radio, called Hobart Air Traffic Control and the sea bed by the undercarriage, which was the blade gear segment teeth that the pitch feet and visibility 3-4 miles. Under these extended. The starboard wing, which had conditions the aerodrome was closed, the gave his position and height and reported settings of both propellers on impact was that the aerodrome lights were in sight. broken off just inboard of the wing attach· 24°. These settings are consistent with the night cloud ceiling minima being 1,950 feet, ments, was found underneath the aircraft and the aircraft was instructed to hold . on Hobart acknowledged and advised that the engines operating at low power and the air­ rotating· beacon would be switched on. The The nose section of the fuselage had broken craft flying at a relatively slow speed. the holding pattern at 4,000 feet on a QNH1> at the rear of the forward door, across the of 1002 millibars~'. Just after 0330 hours captain replied "thanks" and a few seconds later found himself underwater. top of the pilot's emergency exit and clown The nature of the damage indicates that the weather improved to 8/8ths nimbo the starboard side at the rear of the pilot's the aircraft struck the water in an almost stratus cloud with a base of 2,200 to 2,400 The captain surfaced some distance from level attitude with the wheels down and flaps the aircraft and on swimming back to it he window. This section, attached to the fuse­ feet and 2/8ths fracto stratus cloud in two lage by the control cables and about 2 feet up whilst flying at a relatively slow speed layers between 700 and 1,400 feet and at found it floating in a nose down attifode but of skin on the underneath side, was severely under low power. This configuration is sub­ 0333 hours the aircraft wa.s cleared to carry comparatively high in the water. There was stantially the same as that described by the a large hole in the nose of the fuselage and crushed and distorted and was inverted and out an instrument descent on the Visual twisted to the port side of the aircraft. Both captain as being flown immediately before Aural Range (V.A.R.), commencing from he swam in through this to search for the finding himself in the water. first officer but without success. The aircraft propellers had broken from their respective the "Z" marker. The aircraft, which was not engines and both engines were broken off the fitted with Distance Measuring Equipment, sank as he came out of the fuselage. aircraft at their mountings. The captain, who was 32 years of age, held arrived over the "Z" marker at 0334 hours a first class airline transport pilot licence and a left turn through 210° wai;; carried out SEARCH AND RESCUE There was no evidence of any pre-crash endorsed for a number of aircraft including back through the marker, intercepting the When the aircraft had not arrived at the structural failures. Because of the circum­ DC.3 aircraft, together with a first class aerodrome by 0344 hours, i. e., approximately stances surrounding the accident the wreck­ instrument rating for A.D.F., V.A.R. and .; The QNH is, briefly, t he altimeter setting which five minutes after the aircraft had reported age was specifically examined for indications Localiser equipment. At the time of the acci­ if set on the sub-scale of the altimeter ensures that of any type of explosion. There were no signs dent his total flying experience amounted to the instrument indicates height above mean sea having the aerodrome lights in sight, Hobart level. Thus with this setting when the aircraft Air Traffic Control commenced calling the of fire marks, flash burns, embedded or fused approximately 8,100 hours, of which over lands the altimeter should indicate the approxi­ aircraft. No reply was received and at 0350 metal, blast tracks or bulge<\] panels. In 5,000 hours had been flown as a pilot in com­ mate h eight of the aerodrome above sea level. hours, Hobart advised Launceston Air Traffic addition, the possibility of a refrigerator mand of DC.3 aircraft, and this total includes having exploded or the cockpit having be­ some 1,250 hours as pilot in conunand on * Although the instrument approach chart, cunent Control Centret of the circumstances and at this time, specified the minimum holding alti­ emergency procedures were intr oduced. come contaminated from a leak of the re­ night flying. During the five years preceding tude as 5,000 feet the Victoria-Tasmania Region frigerant wa.s thoroughly examined. It was the accident he had made some 120 night :f: Launceston is the a lerting centre. for the Laun­ Airways Operations In struc~ions, Volume 2, Part concluded that the design of the unit is such landings at Cambridge Aerodrome. In the 90 8, Section 8.4.3.l authorized Air Traffic Control to ceston Flight Information Region, which includes that it could not explode and even if the total days preceding the accident he had flo wn a permit holding at 4,000 feet. Hobart.

18 total of 200 hours all on DC.3's and had made The captain's last recollection before the aerodrome lights and the obstruction lights. before impact and at approximately 2,000 25 night landings. His last night landing at impact was that the aircraft was "perform­ Despite the onset of first light, it was quite feet at the conclusion of the procedure turn. Cambridge Aerodrome was 26 days before ing normally" and was descending at about dark below the aircraft. It was concluded The likelihood of enoneous altimeter read­ the accident. Throughout his career he had 200-300 feet per minute at an airspeed of that "there was no external reference or satisfactorily passed each periodic flight ing is least when th~ pil?t is ~once~trating on 100 knots and was at an altitude of 800-1,000 I combination of i·eferences by which the instruments solely, 1.e. m this accident up to check. feet. No evidence was found to suggest that height of the aircraft could have been e~ti­ the captain could have been rendered uncon­ the commencement of the inbound turn at The first officer held a commercial pilot mated with any degree of accuracy durmg which time the ail-craft first broke through licence endorsed as a "DC.3 trainee", which scious before impact and consequently it \ the approach and any attempt to do so could appears that the captain's last recollection of cloud. During the procedure turn, the cap­ permitted him to carry out the duties of a have led to serious errors in the estimation of tain's attention would have been first dis­ first officer on DC.3 freighter aircraft. His the aircraft flying normally was immediately heights." prior to the impact. A reconstruction of the tracted by the lowering of the undercarriage total aeronautical experience at the time of The captain states that he increased the and then by checking the increasing rate of the accident was 360 hours, of which his descent described by the captain places the aircraft at approximately l,o·oo feet when rate of descent t o approximately 1,000 feet descent and adjusting power and trim. The experience on DC.3's amounted to 42 hours per minute immediately on completion of the captain is most likely to have "lost" 1,000 as a supernumerary pilot, 14 hours 30 directly over the point of impact, yet all the evidence contradicts the possibility of any inbound procedure turn, in an endeavour to feet during this turn or else during the more minutes on dual instruction and 17 hours as get to a height below all clo~d on _the re­ rapid descent following it, and it is not diffi­ a first officer. sudden loss of height. Thus, it is concluded that just before impact the aircraft was mainder of the approach. Durmg this stage cult to imagine how he could continue to The weather in the vicinity of Cambridge being flo wn approximately 1,000 feet lower of the approach he was discussing various misread the altimeter after making an initial Aerodrome at the material time was- than the captain believed it to be and was features of the descent with the first officer error. inadvertently flown into the water. and operating the radio in addition to looking The pilot in command had experienced an Visibility 3 to 4 miles; no wind; no tur­ outside the aircraft and reading the instru­ active day prior to the accident. He was for bulence; Cloud - 8/ 8ths strato-cumulus, Particular attention was paid to the alti­ ments. In these circumstances he would be several hours driving a tractor on farming tops 5,000 feet, base 2,500 feet with nimbo­ mete1·s and the static system but after an able to devote limited attention to the instru­ work and was able to retire to bed for only a stratus at the base of the strato-cumulus exhaustive examination it was concluded ments. little more than two hours before driving 35 reducing the effective base to 2,200-2,400 that both altimeters were functioning Tests carried out in the United States of miles to the Melbourne Airport to undertake feet; also two layers each 2/8ths to 3/ 8ths properly and the proper barometric settings America indicate that U.S.A.F. pilots flying this flight. The possible influence of fatigue fracto-stratus between 700-800 feet and were being used at the time of the accident. solely on instruments spend an average of as a factor contributing to the accident can­ 1,200-1,400 feet; this low cloud was mainly about 4/ lOths of a second on reading the alti­ not be overlooked. over the land; drizzle and light rain The captain stated that as the inbound procedure turn was completed, the aircraft meter and rate of descent indicator at a time, Taking all things into account it is con­ around Frederick Henry Bay but no rain and that this time is insufficient to ensure on south-east leg of the V.A.R. or over the was clear of cloud and he could clearly see sidered that the probable cause of the acci­ aerodrome at the time of the accident. the beaches (around Frederick Henry Bay) accurate altimeter readings, on all occasions. dent was the reliance the pilot in command and shortly afterwards some lights on the In these tests 11.7 per cent. of all altimeter placed on inadequate external i·eferences for readings were in error by 1,000 feet or more. ANALYSIS aerodrome and the obstruction lights on his estimation of altitude and his failure to Single Hill and Mt. Rumney became visible. However on this occasion the captain was give enough attention to the flight instru­ The plan on page 16 shows the path for the During this stage of the flight the captain not conc~ntrating solely on instrument flying, ments. The unorthodox approach carried references available were the coastline, the says that he was flying partly by reference and between his comparatively infrequent out whilst not directly unsafe in itself, lacked approved V.A.R. instrument approach and to the instruments and partly by reference glances at the altimeter its readings were ste~diness and precision in a way that the path flown by the aircraft on this flight. to external objects and that "first light had changing at irregular rates due to the va1·y­ afforded the opportunity for errors, and As can be seen from this plan the approach appeared to an extent which could have just ing rates of descent; it is considered that all thereby possibly contributed to the accident. adopted on this· occasion differed from the permitted me to land without reference to these factors, together with the absence of approved procedure in certain important any lights but with reference to the ground external indications of altitude, increase the CONCLUSIONS aspects. Notably, the inbound procedure alone." He states further that he estimated possibility of error in reading the altimeter, turn was completed at an altitude 1,000 feet his altitude visually with reference to the which the U.S.A.F. tests have shown to be 1. At approximately 0340 hours on the below the altitude specified in the approved "beaches and Single Hill" (obstruction light). high under normal conditions of instrument 12th January, 1956, a DC.3 aircraft crashed approach procedure for the completion of It appears from the captain's statement that, flying. into Frederick Henry Bay, 6t miles south­ east of Cambridge (Hobart) Aerodrome, that turn. although he checked occasionally with the The various tests .conducted in the United altiineter, he used the external references to Tasmania~ The wreckage was located at An analysis of the approach path adopted Stat es have shown that the altimeter is the this position in 50 feet of water. estimate his height and was confident that instrument most frequently misread. The on this occasion, indicates that, although his estimation was accurate, and not in dis­ 2. At the time of the accident the aircraft non-standard, under the circumstances it was most common error is to read 1,000 feet too agreement with his altimeter observations. high and this occurs mostly when the sensi­ was flying in darkness clear of cloud and not inherently unsafe, but there were seve1·al with the aerodrome lights in sight, having undesirable f eatu res in it. The more serious tive hand is near zero or just below it. For Following this accident a flight simulating­ example, when the altimeter is indicating just carried out an instrument approach were that the minimum altitude was not that on which the accident occurred was through low cloud. It struck the water in a observed during the inbound procedure turn, 1.900 feet, the thousands hand is pointing carried out for the purpose of examining· almost directly at 2 whilst the sensitive hand normal flying attitude. and, as is discussed later, the rates of descent the external visual references available to varied and a high rate of descent was adopted is at 9. It is easy to misread this altitude as 3. The weather, at Cambridge Aerodrome the pilots under the conditions at the time. 2,900 feet, exactly 1,000 feet too high. In was 8/ 8ths nimbo-stratus cloud with a base when the aircraft was at a relatively low This flight established that the only external altitude. this accident it is significant that the captain of 2,200 to 2,400 feet and 2/ 8ths fracto­ reference available were the coastline, the believed he was flying at 800-1,000 feet just stratus cloud, in each of two layers, between 20 21 700 to 1,400 feet. There was no wind, no no indication of malfunctioning controls, turbulence, the visibility was 3-4 miles and structlU'al failure, fire or explosion. some turbulence near the ground. The cir­ It was concluded that the probable cause it was dark; first light had started to appear cumstances of the loss of height suggested behind the. aircraft on its final course. 9. On departure from Melbourne Airport of the accident was the failure of the pilot the all-up-weight was less than the maximum that the aircraft was being operated below to maintain a safe airspeed under the con­ 4. The aircraft was engaged on a special permissible and the load was distributed so a safe airspeed when it encountered a down­ ditions of load and turbulence. flight and the only occupants were the cap­ that the centre-of-gravity was well within draft which, in view of the low airspeed was tain and the first officer. the prescribed limits. However the pilot in of sufficient strength to cause the aircraft to command did not take reasonable steps to lose height. As the aircraft "dropped" the Legal proceedings, taken against the owner 5. The captain, who was thrown clear of ensure that the load carried was, in fact, so pilot pulled back on the control column and in for removing the wreckage without permis­ the aircraft on impact and was rescued from distributed as to be safe for flight. doing so placed the aircraft in a nose high the water some 2! hours later, received attitude at such low airspeed and altitude sion, resulted in a fine of £30 with costs for serious injuries. Despite his injuries he swam 10. Contrary to the requirements of that, despite the application of full power, contravention of Air Navigation Regulation into the sinking aircraft in search of the Regulation 159, the pilot' in command failed the aircraft steadily lost height. 275. first officer. The first officer, who was prob­ to comply with the approved instrument ably rendered unconscious through injuries approach procedure for Cambridge, as pre­ Helicopter Accident near Morehead, New Guinea received on impact, was drowned. scribed in Aeronautical Information Publica­ tion R.A.C.-2. (6/ 455/27) 6. The aircraft sustained major damage by impact and submersion in the salt water. 11. CAUSE: The probable cause of the URING an approach to land at the heli­ failed. The ball race cage on the inboard Damage to other property was confined to accident was that the pilot in command port near Morehead, New Guinea, a side was broken into a number of pieces, all the freight, which was also virtually a total relied on inadequate external visual refer­ D Bell 47Dl helicopter crashed among of which were considerably distorted. In loss. ences for determining the altitude and paid logs· adjacent to the landing platform and addition to being a radial bearing, the ball insufficient attention to the instruments, sustained substantial damage. The pilot was race holds the rotor shaft in position, i.e. 7. The aircraft was operating under cur­ particularly the altimeter. uninjured. acts as a thrust bearing. Failure of this race rent certificates of registration, airworthi­ will allow the tail rotor shaft bevel gear to 12. The irregular approach procedure car­ The helicopter, which was engaged in ness and safety (in lieu of a maintenance supply work, departed from a dynamite move out of mesh with the drive shaft pinion release) and all maintenance records were ried out by the pilot in command deprived gear. Thus the tail rotor would be discon­ him of the opportunity to monitor the safe supply base for Heliport F21, a distance of in order. approximately 7 miles. The pilot, who held nected from the main rotor and directional approach to the aerodrome through the control lost. 8. All major components of the aircraft correlation of time, height and position. a commercial helicopter pilot licence, report­ were recovered and an examination revealed This probably contributed to the accident. ed that the descent into the heliport was It was concluded that the cause of the normal until, at a height of about 10 feet accident was loss of directional control at a above the ground and just short of the land­ very low height when the tail rotor drive Take-off Accident near Stannum, N.S.W. ing platform, the collective pitch was raised became disconnected as a result of the dis­ and power applied preparatory to lowering integration of a ball race in the tail rotor (6/255/131) the helicopter onto the landing platform. At gear box. this moment the helicopter fuselage turned HORTLY after taking-off from an air­ By this time it was impossible to clear the rapidly through 90° despite the application The ball race and other relevant compon­ strip 4 miles north-west of Stannum, rising ground and the aircraft struck a tree of full left rudder. The pilot was unable to ents were forwarded to the helicopter manu­ S New South Wales, a DH.82 engaged in with the starboard mainplane and crashed turn the helicopter fuselage back towards facturers for investigation and it was deter­ aerial agricultural operations crashed into into the ground. the landing platform and commenced to move mined that the breakdown of the ball bearing rising ground. assembly was due to either- The pilot was the holder of a commercial it sideways, but almost immediately the The aircraft was one of a number of pilot licence with a total aeronautical exper­ fuselage began to rotate rapidly and he had (a) the failure of the bearing cage which DH.82 spreading fertilizer in the area. After ience of 2,306 hours. His total aerial agri­ no alternative but to lower it to the ground. released the bearing balls and allowed experiencing some difficulty with take-offs cultural experience amounted to 50 hours. The helicopter still turning touched down in pieces of the cage to find their way into the north-west, it took-off into the a clear area 45 feet from the landing plat­ between the mating gear teeth, south-east, and after holding the aircraft There was no evidence of pre-crash defects form but bounced slightly to the right and down until the airspeed was "in excess of or malfunctioning that may have contributed the port pontoon struck a tree stump. The or 65 m.p.h." the pilot commenced to climb to the accident. helicopter came to rest in an inverted posi­ (b) a piece of foreign metal worked its straight ahead. At a height of about 80 feet, The aircraft took-off on this flight with . tion. way between the mating gear teeth he completed a climbing turn to the left with 448 lb. of super-phosphate in the hopper, Examination of the wreckage revealed and produced an impact thrust which full power applied and then levelled out and although the maximum weight authorised that the tail rotor gear box ball race had failed the bearing and its cage. reduced power. At this moment a severe up­ was 350 lb. The all-up-weight of the aircraft ward jolt was experienced as the aircraft com­ was 1,945 lb., 120 lb. in excess of the maxi­ Collision with High Tension. Wires menced to lose height. Full power was mum permissible weight as specified in its applied and an endeavour was made to certificate of airworthiness. (6/156/46) operate the dump valve release lever. As this was inoperative the normal dropping valve The weather conditions at the time were T Thorpdale South, Victoria, a DH.82 and calm with unrestricted visibility when warm and humid and there was undoubtedly flown by a licensed commercial pilot the aircraft prepared for another run across was opened. A was engaged in spraying parathoin the field. However, during this run, and over a potato crop. The weather was fine 22 when in a shallow dive, the aircraft struck 23 high tension wires, completed a back somer­ height of the wires above the ground de­ rear cockpit. It was concluded that either sault and struck the ground at an angle of creased, the aircraft became closer to the proach into a field similar, but adjacent, to about 40°. The pilot, who was the sole wires, until they were struck at a point 75 one 01· both of the aircraft had some left the approved forced land in~ ground. . In occupant, received serious injuries to both feet above the ground. bank applied at the moment of impact, that view of the relatively low altitude at which legs and the aircraft was rendered a total the starboard tyre of one aircraft was on the collision occurred, it is probable that the loss by impact damage. The pilot stated that he was not aware of top of and near the wing root of the star­ pilot of VH-RVA was also. engal?;ed . on the existence of the high tension wires and board mainplane of the other and the port forced landing practice, possibly clrmbrng The potato field was approximately 130 at no stage of the flight did he see them. The tyre below the starboard mainplane. at the away from an approach, ~nd tm~ning to the feet in length and separated from the landing· power line was erected approximat ely two inboard end of the slat, and that the "turtle­ left across wind at the time of impact. As field to the north by a gully. A high tension weeks prior to the accident and as the pilot back" of the lower aircraft was struck by a not~d above VH~RVA had just completed a power line runs alongside the landing field had operated in the area on a number of tyre as both aircraft momenta!ilY main­ steep turn. In view of the probable flight and continues across the gully and passes occasions, he apparently considered that h e tained their line of flight after impact. paths both pilots were considered tc? have approximately 600 feet to the west of the was sufficiently familiar with the area. Impact damage to VH-RVE included tear­ ample opportunity to see the other aircraft potato field. The height of the wires above the and take avoiding action long before the ground was approximately 130 feet decreas­ It was concluded that- ing away of the lower eye end of the port (a) the cause of the accident was that radius rod and breaking of the upper fork aircraft were in dangerously close prox­ ing to qpproximately 50 feet at a point in imity. line with the southern boundary of the potato the pilot, whilst engaged in authorised end of the undercarriage. This allowed the field. The spraying runs were made at about low level aerial agricultural opera­ port undercarriage leg to swing back .a fter Both pilots had approximately 21 hours 5 feet above the crop and the pilot was re­ tions, inadvertently flew the aircraft being br oken and damage the port aileron flying experience under .instruction ar.id 12 quired to continue beyond the wires before into high tension wires; and cable balance and lower control lay shaft hours solo flying at the time of the accident; making a turn back towards the field. Dur­ (b) the presence of the wires in the area bracket. It is considered that the probable all on DH.82 aircraft. The weather was fine ing these turns some 50 to 100 feet of height of operation was not known to the consequent r estriction on aileron move~ent with unlimited visibility and a wind of 6-8 was gained and then a shallow dive to the pilot because he failed to adequately resulted in the loss of control by the pilot. No other defects or evidence of malfunction­ knots from the south. There were no other required height was made. As the spraying familiarize himself with the area aircraft in the area at the time. runs continued towards the south, and the before commencing operations. ing which might have contributed to the loss of control were found, The cause of the accident was considered Evidence suggested that the pilot of VH­ to be the failure of both pilots to maintain DH-82 Mid-Air Collision near Werribee, Victoria RVE was making his forced landing ap- a p~·oper watch for other aircraft. (6/155/13) WO civil DH.82's, VH-RVA and VH­ to the left". Immediately he found difficulty Fatal Stall in DH-82 RVE, being used under contract to give in controlling the aircraft which commenced (6/ 355/ 1). Tflying training to R.A.A.F. National to lose height and turn to the left. Whilst Service trainees, collided at a height of about attempting to control the aircraft he noticed LEVEN light aircraft taking part in The pilot of the DH.82 stated that he 1,000 feet and crashed into a field near another aircraft crashed in a field almost a field day at Coolangatta departed failed to understand the signalling of the Werribee, Victoria. The pilots of both air­ below him. He attempted to carry out a E from Ar cherneld aerodrome at 1245. other aircraft and continued along the beach. craft had been authorised to carry out forced landing in the same field but just The departure had been delayed due to for~­ The DH.82 then commenced a climbing left periods of solo flying including side-slipping, before touching down, lost control complete­ casted storms in the area. Soon after thell' turn towards Archerfield ; the pilot stated steep turns, spins and forced landings. The ly, and crashed about 600 yards from the arrival at Coolangatta, a distance of 46 miles that in this turn the aircraft slipped to the pilot of VH-RVA was killed on impact with other aircraft. from Ar.cherfield, the aircraft were in­ left and lost heig·ht. The aircraft then stalled .the ground and the pilot of VH-RVE received structed to return as storms were forecast and crashed onto the beach. Several fisher­ minor injuries. Both aircraft were destroyed. Inspection of the aircraft wreckage re­ for the area by 1600 hours. men removed the pilot and passenger from The attention of a group of people was vealed, in the case of VH-RVA a mark on the A DH.82 carrying a pilot and a passenger the wreckage. The passenger received exten­ attracted by a noise above them and on look­ top of the leading edge of the starboard departed from Coolangatta on the return sive head injuries and died a few minutes ing up they saw an aircraft, with the main­ upper mainplane two feet from the wing later ; the pilot was seriously injured. root, consistent with its having been flight to Ar cherfield. A second aircraft which planes missing from one side, almost verti­ departed six minutes later, flew nortJ;i to Examination of the engine and airframe cally in a tight spiral to the right. It crashed struck by an aircraft tyre, and a severe Southport because of a storm on the direct impact mark smeared with aircraft dope on disclosed no defects, maladjustments or in the field shortly afterwards. The other route, and obser ved the DH.82 flying at a evidence of malfunctioning. aircraft was observed to descend, turning to the starboard tyre of VH-RVE. Ma1·ks on height of 1,500 feet. The DH.82. was seen the left, and crash in the same field. the starboard upper wing slat of the former to descend and fly at a very low height above The pilot held a current private pilot aircraft were consistent with its having been licence. His total flying experience amounted The surviving pilot stated that, at the the beach on South Stradbroke I sland. '!'.he struck by an aircraft undercarriage; there weather at the time was 5/ 8ths cloud with to 121 hours of which 101 hours had been time of the collision, he was making his were fractures in both spars of the respec­ flown on DH .82's. second consecutive practice forced landing a base of 2 000 feet, but visibility was un­ tive upper mainplane in line with the inboar d The wind was from the north at the time approach from a height of 3,000 feet. At end of the slat. It was also apparent that restr icted · there was a storm situated 10 about 1,200 f eet, as the aircraft came out miles west of the island. After flying along­ of the accident and as the aircraft, which had subsequently both starboard mainplanes side the DH.82 and endeavouring to "wave been flying towards the nor th entered a of a steep turn preparatory to turning into failed at the wing root and folded rearwards. wind toward the forced landing field, the him up and in the direction of Archerfield", climbing turn to the left. it wou!d commence A further tyre mark was found diagonally to drift to the left. It is possible that the pilot, "felt a bump and the aircraft yawed across the top of the fuselage behind the because of forecasted weather deterioration, the air craft flew off. pilot was misled by the drift into believing 24 25 t hat the aircraft was "slipping" during the The cause of the accident was misuse of dive when it struck the ground. There was The pilot held a private pilot licence and turn and that he attempted to correct this the flight controls by the pilot during the no indication of engine malfunctioning that had a total aeronautical experience of 138 "slip". It is apparent that the pilot misused climbing turn, possibly arising from a mis­ may have contributed to the accident. hours of which 12 hours had been flown in the flight controls during the turn and t his command of Proctor aircraft. The aircraft taken impression on his part that the air craft The south-west stream which existed gave resulted in the air.cr aft stalling. was "slipping" during the t urn. was equipped with a full instrument panel r ise to considerable cloud on and south of but the pilot was relatively inexperienced the r anges and the weather in the vicinity and had had no training in instrument flying. Nose Heavy Norseman, New Guinea of the scene of the a ccident at the material His only course of action was to find a break time was 7 /8-8/ 8ths strato-cumulus base in the cloud and descend as soon as possible. (6/455/ 22) 1,500 f eet, with good visibility below cloud. HE difficulty of assessing the bearing landing run of some 800 to 1,000 feet would It was concluded that:- st rength of every part of the surface of It is probable that the flight was made have been r equired. However, the air craft below cloud until nearing the ranges, the (a) The probable cause of the accident T a newly-constructed natural surface travelled for approximately 1,150 feet from was loss of control by the pilot whilst airstrip in the highlands of New Guinea highest of which is Mt. Slide, 1.,600 feet the point of touchdown, following an oblique above M.S.L. and H miles W.N.W. of the flying in cloud resulting from his in­ particularly after rain, contributed t o a~ path toward the side of the strip when t he experience of instrument flying; accident in which a Noorduyn Norseman air­ wr eckage site. The pilot was then for ced to wheels sank into soft ground and the air­ climb to clear the r anges and probably com­ (b) A contributory cause was an error of craft over t urned while . landing at the craft tipped onto its back. licensed aerodrome at Ialibu. menced fl ying bet ween breaks in the douds. judgment on the part of the pilot in The pilot had omitted to compile a load­ However, within a few miles the breaks attempting to continue the flight in On the day before the accident, the strip sheet for the flight on which no freight or became smaller until finally he lost visual conditions in which continuous visual had been inspected by Departmental officers ballast was being carried. Even with the contact with the ground. flight became impossible. and a Class 1 N otam issued opening· the strip fuel quantity giving the best weight distri­ for operations by Norseman aircraft, subject bution the c~ntre-of-grav ity would have been to a rainfall restriction of not more than 100 at least 7 inches in front of the permissible DH-82 Take-off Accident points in 24 hours. The accident occurred forward limit throughout the flight. This (6/ 255/ 81) during the first landing after the airstrip was would make t he aircr aft dangerously nose­ opened, 55 points of rain having fallen in the hea vy in flight and on t he gr ound. Despite HILST engaged on aerial agricultural feet in length running north-south and the previous 24 hours. the unserviceability of part of t he airstrip operations a DH.82 took off and after other 1,350 feet r unning east-west. The there is a possibility that the air craft would W successfully negotiating a hill immed­ terrain rises steeply within half a mile of The strip is orientated on a bearing of iately off the end of the strip, lost height and each end of the north-south r unway and 115°T with a 2 per cent upslope to the east. not have overt urned had the centre-of­ gr avity been within the allowable limits. struck the ground. The pilot, the sole occu­ within a few miles on all sides the ground Weather at the time of t he accident was fine pant, received minor injuries and the air­ rises steeply to some 3,000 feet above the with the wind from 100°T at 16 knots. The The pilot had accumulated 1,785 hours up craft was substantially damaged. aerodrome. This aerodr ome does not meet pilot made a normal approach to land into to t he time of the accident, including 897 the minimum requirements in respect of the east and touched clown slightly to one hours on Norseman aircraft in New Guinea. The pilot ·who had limited experience on aerial agricult ural operations, proceeded to length, width and longitudinal grade between side of the centreline of the strip and some The cause of t he accident was that the runway ends or approach angles as specified 600 feet from the western end. It has been "Booraig" Station aerodrome near Talbingo, aircraft, loaded dangerously nose heavy, N.S.W., and carried out a successful ferti­ in the Aeronautical Information P ublication. calculated that under t hese conditions and encountered a soft patch on the airstrip assuming the surface to be " wet grass" a lizer operating flight. On the second flight, The weather was fine with unre·stricted during the landing r un. the aircraft took off into the south and after visibility and the wind on the ground was becoming airborne the pilot climbed it over light and var iable. The all-up-weight of the Proctor Lost in Cloud a 400 feet hill immediately off the southern aircraft on take-off was 37 lbs. in excess of end of the strip. The pilot reported that as the maximum permissible all-up-weight (16/ 2/26) . the -aircraft passed over the hill with about specified in its certificate of airworthiness. URING an early morning flight from flight details for a V.F.R. flight below the 50-60 feet clearance, he "experienced a sud­ The evidence revealed that after take-off Moorabbin, Victoria, to Canberra, a controlled airspace. The aircraft was cleared den jolt and the aircraft seemed to fall the pilot attempted to climb over high ter­ D Percival Proctor carrying a pilot and to fly below 1,500 feet above the terrain. The r apidly". The pilot released the fer tilizer and rain r equiring a gradient of climb beyond t wo passengers crashed on the side of a clearance was acknowledged and no further '".ook corrective action but was unable to pre­ the performance of the aircraft. It is con­ steep, heavily timber ed ridge at the head of communications wer e r eceived from the air­ ;rent the aircraft losing height ahd it st ruck sidered that the accident was caused by the the Dixon's Creek valley, 4t miles E.S.E. of craft. t he gr ound. pilot's inexperience and lack of a:ppreciation Kinglake, Victoria. The occupants were Witnesses in the Kinglake area r eported "Booraig" Station aer odrome consists of of the hazar ds which must be expected when killed and the aircraft disintegrated on im­ • operating amongst hills. pact. having seen the aircraft "appear out of two grassed runways 40 feet wide, one 1,200 cloud in a steeply banked attitude descending The aircraft was engaged on a private rapidly in a vertical dive". Anot her witness Mid-Air Collision at Narromine, N.S.W. flight and prior to departure the pilot re­ r eported having heard the aircraft circling ceived a route forecast which indicated that over Mt. Slide a few minutes prior to its (6/ 255/ 159) the weather over the route was influenced appearance through t he cloud. HEN two DH.82s, VH-AVX and late afternoon, the two occupants of each air­ by a south-west stream, and 7 /8ths cloud, An examination of the impact marks and VH-BKO, collided almost head-on at craft we1·e killed instantly. Immediately base 3,500 feet, could be expected until north lack of damage to surrounding t r ees revealed W a height of about 1,000 feet over following the collision the aircraft crashed, of the Victorian ranges. The pilot submitted that t he aircraft was in an almost vertical Narromine, New South Wales, during the about a half mile apart, into the Nar romine

2G 27 township. Both aircraft disintegrated on some verbal instruction and both were con­ impact with the ground. No other persons centrating on positioning the aircraft in were injured and the damage was confined relation to the landing path, which was on to a small outbuilding and the roof of an the left and consequently neither was main­ PART IV hotel. taining a regular watch to the right of thefr aircraft. The visibility at the time was good THE CIRCUMSTANCES and as the aircraft was on an easterly head­ ing, the pilots' visibility would not have been INCIDENT REPORTS Aircraft VH-AVX was being flown (from disturbed by glare. At the angle at which Narromine aerodrome) by the .chief flying the aircraft converged, the other aircraft instructor of the . local Aero Club with a would have been within the pilots' range of student pilot on a dual flight. Aircraft VH­ vision for at least 26 seconds, the time it took BKO departed from N arromine aerodrome for the aircraft to close one mile. Near Miss during l.F.R. Descent, Rome approximately 10 minutes later on a local private flight carrying one passenger. At the time of the accident, VH-BKO was (6/855/ 63) flying a mile and a half south of the aero­ Witnesses reported having observed the drome on a westerly heading. Being in the N Australi1ln Constellation aircraft en­ Civil Aviation Authorities follow the ICAO aircraft when they were about a half mile vicinity of the aerodrome, it would be ex­ route from Cairo to Rome was cleared procedure whereby if a pilot files an I.F.R. apart. Aircraft VH-AVX was on an easterly pected to conform with or avoi~ the pattern A for an J.F.R. descent into Rome and flight plan for flight in a control area he heading while aircraft VH-BKO was on a of traffic formed by other aircraft as required ~o report at I.KO. N.D.B. inbound at 3,000 receives separation only from other aircraft westerly heading with both aircraft flying by Air Navigation Regulation 143 (b). There feet. Whilst approaching the N.D.B. south­ operating on I.F.R. flight plans. He is neither straight and level at a height of about 1,000 are no special directions regarding aircraft bound at 3.000 feet, the captain noticed separated from nor advised of aircraft feet. There was no apparent deviation in in the circuit area at Narromine aerodrome another Constellation flying at the same operating under V.F.R. clearances. Under their flight paths and the starboard upper and therefore in accordance with Regulation height but heading north. The captain took this concept, therefore, if a pilot is operating mainplane of VH-AVX passed between the 143 (c) the circuit pattern was to the left. immediate avoiding action by diving beneath I.F.R., but in V.F.R. conditions, he must still starboard mainplanes of VH-BKO. The lead­ Aircraft VH-BKO was being flown against the other aircraft with the result that the be on the alert for V.F.R. aircraft. ing edge of the starboard upper mainplane this. Although the sun was at ah altitude of aircraft passed within 250 to 300 feet of each Traffic operating along controlled air of VH-AVX struck and dislodged the star­ five degrees above the horizon, and the pilot's other. The other aircraft which was on a routes in Australia is controlled so as to board interplane struts of VH-BKO and the forward vision would have been affected to V.F.R. clearance out of Rome was obviously maintain positive separation between V.F.R. then unsupported starboard upper mainplane a considerable degree by glare, it is con­ unaware of the danger and took no avoiding of VH-BKO failed at the wing root and sidered that in view of this condition the action. and l.F.R. aircraft. For the benefit of pilots parted from the aircraft. Almost simul­ pilot should have exercised the utmost care, on international flights, this in.cident is taneously the starboard lower mainplane of particularly in the vicinity of the aerodrome. The matter was referred to the Rome reported as a reminder of the control con­ authorities who advised that the other Con­ VH-BKO struck and dislodged the starboard The pilot of aircraft VH-BKO was a cepts currently in use in other countries, interplane struts of VH-AVX. stellation was en-route Rome-Zurich and was private pilot licence holder with a total flying climbing on a V.F.R. clearance. The Italian including Italy and the United States. The collision occurred over the Narromine experience of 48 hours, all on DH.82s of townsnip at a point approximately lt miles which 29 hours had been flo wn under instruc­ south-east of the aerodrome. In the impact, tion and 19 hours solo. The Need for Vigilance in the Control Zone portions of each aircraft wer e torn away. An examination of those parts of the Aircraft VH-BKO entered an almost verti.cal structure, joints and attachments still intact (6/ 356/ 9) spiral dive, crashed onto a small outbuilding showed that they were in a satisfactory con­ URING a summer evening at Brisbane trouble. In the meantime VH-EBN had in the back yard of a house and burnt on dition, and all failures appeared new and airport an incident occuned which asked for taxying instructions and VH-ANM impact with the ground. Aircraft VH-A VX consistent with the forces of collision or D illustrates well the necessity for maxi­ had reported 20 miles north of Brisbane air­ entered a steep spiral dive and crashed into in1pact with the ground. mum vigilance by pilots and controllers when port. VH-EBN was given runway 08 for a minor street. A slat which became detached take-off (i.e. the reciprocal of the landing CAUSE operating in a control zone under night from the starboard wing landed on the roof visual conditions. Arriving traffic at the duty runway), the controller endeavouring of an hotel. The cause of the accident was the failure time consisted of two DC.4s (VH-ANC and to keep taxying distance and traffic delays of the pilots in both aircraft to take such VH-TAB) approaching Brisbane from the for this air"craft to a minimum. VH-ANM ANALYSIS precautions as would enable them to see other south, one DC.3 (VH-ANM) from the north was given No. 2 in the traffic sequence follow­ ing VH-ANC and replacing VH-TAB. VH­ At the time of the collision, aircraft aircraft. and one Viscount (VH-TVD) from the south, and they were due to arrive in that order. TVD which had just reported 20 miles south VH-AVX fl ying in an easterly direction, was A contributory cause was that the pilot of of Brisbane airport was asked to report probably on the downwind leg of a left-hand aircraft VH-BKO flew his aircraft in the Denarting traffi..c at this time was one DC.4 (VH-EBN) bound for Sydney. passing Archerfield, to land on runway 26 circuit with the intention of landing into the vicinity of the aerodrome against the traffic and was advised No. 2 in traffic (VH-ANC west-south-west. It is also probable that at pattern in apparent disregard of Air Navi­ VH-ANC landed first on runway 26 with­ the time, the instructor was giving the pupil gation Regulation 143. out incident but VH-T AB experienced had landed by this t ime). hydraulic trouble when on final approach VH-EBN was cleared for take-off into the and obtained permi ~sion to orbit south-east east· setting .course on the 125°M diversion of the fi eld whilst enileavonring to rectify thi; track whilst VH-ANM from the north had

28 29 been requested to make a left circuit and the position of VH-TVD when the Archer­ Where you can assist A.T.C. land No. 1 into the west. The captain of field report became overdue but he assumed VH-TVD omitted to report passing Archer­ that, since the aircraft could not be seen NDER certain circumstances, pilots are this question arises (e.g. VFR approaches, field and in addition made a rather wide along the usual circuit entry track, it was not required to report vacating altitudes position reports - particularly check points sweep to the east of circuit area to lose in or near the circuit. l\. reasonable exchange U when proceeding to a newly assigned - approaching the circuit area) and,in an height and at the same time line up on the of information between the pilot and the con­ altitude. In the past, on numerous occasions, endeavour to reduce the amount of unneces­ duty runway. He did not keep the airport troller could have avoided this incident. pilots have omitted this item from their sary chatter the Department is ensuring that controller informed of this action. As VH­ transmissions and because it has not affected all air traffic controllers use clear, concise TVD entered the circuit area from the south­ The action of the airport controller in the traffic situation, Air Traffic Control have instructions and where possible, standard east the crew noticed VH-EBN take-off and allowing VH-EBN to take-off in the not always pressed the pilot for the informa­ phraseologies. It should then be unnecessary turn climbing towards them on the diversion tion. However, with the build up of traffic over for pilots to ask for a repeat or explanation reciprocal direction to the landing traffic of instructions - we are attempting to track. They flashed a landing light to was not of itself unsafe but his decision to recent years and the introduction of faster identify their position and then turned away allow the take-off in the middle of a landing and high-flying aircraft capable of greatly alleviate the problem, the rest is up to you. to the left to avoid the departing aircraft. sequence without full knowledge of the posi­ increased rates of descent and ascent, it is And one last point- taxying. Under peak As they did so VH-ANM on left downward tions of all approaching aircraft was in­ becoming increasingly important that pilots traffic conditions airport controllers are fully leg and No. 1 to land passed immediately correct. VH-EBN should have been held report vacating, or reaching, altitudes as is occupied making the best use of available beneath the Viscount. Both aircraft then until all arriving aircraft had landed or at required by the A.LP .'s. runways and taxiways. Works are in pro­ landed safely in the correct sequence. least until it was positively known that the gress throughout Australia to improve fa.c­ Similarly, unless otherwise notified, Air ilities but no amount of organization will This was certainly an unnecessary incident departure track would be clear of other Traffic Control expect an aircraft to com­ traffic. prevent incidents caused by pilots misunder­ which could have had more serious results. mence descent immediately an instruction is standing the holding point to which they are The investigation showed that the responsi­ acknowledged by the pilot. For various cleared and entering the runway when an bility should be borne equally by the airport This incident emphasises that careful note reasons, a pilot may not wish to commence aircraft is on final ; or sitting on the duty controller and the captain of VH-TVD. should be made of traffic information passed descent immediately; if this should be the r unway out of communication with the con­ Obviously the airport controller lost track by the airport controller so that each pilot case Air Traffic Control should be immed­ troller (possibly clue to flat aircraft batteries of VH-TVD after it reported being 20 miles can establish at least a mental picture of the iately advised. This aspect of control has and engine RPM too low to cut in the gen­ south of the airport and this was partly due traffic disposition, how it will probably always been important but with the intro­ erators) ; or the misinterpretation of instruc­ to the omission by the captain of VH-TVD develop, and where his aircraft fits into it. duction of separation based on DME distance tions received on the cockpit speaker-in this to report at Archerfield, and also his action Keep this picture up-to-date and .check it by - which will reduce the existing standards case headphones were available and the use in making a wide sweep to the east without listening to other communications traffic on - immediate compliance, or notification of of these may have avoided the incident. advising the airport controller. The con­ the airport control frequency as you ap­ inability to do so, will be an absolute neces­ Occurrences of these types are occurring troller could have and should have queried proach and operate in the airport circuit. sity to ensure the safety of aircraft opera­ frequently and any one of them might easily tions. develop into a serious incident. All concerned It will be realized that whenever Air could easily eliminate such hazards and raise Traffic Control is required to make a trans­ the standard of flying safety even higher V.F.R. and "Visual" Approaches mission to obtain information which should than is presently obtained. be given voluntarily, the channel is being Closer attention to matters such as those BJECTIONS have been raised by pilots the "ground" visibility must be equal to or cluttered up with unnecessary transmissions. referred will avoid hazardous situations holding in the vicinity of, or approach­ greater than the highest minimum prescribed There are many other examples of where developing. O ing, the destination aerodrome, to the for the aerodrome. effect that when visual flight has been estab­ lished well above the landing minima and However, it should be noted that separa­ possibly without the necessity for an instru­ tion with all other aircraft will be based on ment approach, refusal has been given for a the normal I.F.R. standards for the aer-o­ V.F.R. approach when there has been an­ drome unless the aircraft performing the other aircraft in the area making a "visual" "visual" approach can be sighted by the approach. · controller, when control may be based on visual observation. Naturally the application . This situation can arise whenever the of I.F.R. separation standards will require weather is such that it may be possible to other aircraft in the sequence to maintain establish visual flight some distance from the assigned altitudes and possibly hold at an aerodrome but the weather at the aerodrome intermediate point en route to the aerodrome. precludes the authorization of V.F.R. ap­ proaches.. Under these circumstances the No doubt some of the confusion in the past controller may permit a "visual" approach has arisen due to the loose use of the term as distinct from a V.F.R. approach. That is, V.F.R. approach. In the future the terms the pilot must be able to proceed with con­ visual approach and V.F.R. approach will be tinuous visual reference to the terrain, and used in their proper sense. 31 30 I [ · 1 ' !

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