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COMMONWEALTH OF AUSTRALIA

DEPARTMENT OF CIVIL AVIATION j

.. AVIATION SAFETY DIGEST

No. 8

DECEMBER, 1956

Prepared by the Division of Published by Authority Prinled by Mclfe11n lfro1., 41 R11nllin1 Road, K•min1ton. Accident Investigation and Analysis of the Director-General II CONTENTS ,.

PART I -AVIATION NEWS AND VIEWS Page Aircrew Fatigue . . . . 2 Avoidable Collisions on Agricultural Operations 5 Use of Antihistamines . . 6 Serviceability of Licensed Aerodromes 7 Help Others to Help You 7

PART II -OVERSEAS ACCIDENTS Landing Accident - DC6B - Jamaica, New York 8 DC.3 Landing Accident - Yakima, Washington 12 Viscount T raining Accident - Blackbushe, England 13 Martin 404 Take-off Accident - Pittsburgh, Pennsylvania 14

PART Ill - AUSTRALIAN ACCIDENTS Accident to Avro Anson near Hawk.stone Peak, Western Austra lia on 4th February, 1956 17 Ryan Forced La nding - Bankstown, N.S.W. 21 Helicopter Take-off Accident, New Guinea 21 Norseman Forced Landing: Minj, New Gui'nea . . 22 Fatal Chipmunk Accident - New Park Siding, N.S.W. 23 Fatal Auster Accident ...... 23 Overloaded DH .84 crashed at Togoba, New Guinea 24 Auster Collides with Tree Whilst Spraying . . 25 Fatal Aerial Spraying Accident - Collision with Power Li nes ...... 25 Collision with Wires near Maffra, Victoria 26 Collision with Power Lines 27

PART IV- INCIDENT REPORTS Incorrect Heading . . 28 Information Breakdown: Communications Breakdown 29 Tractor and Roller Cause Missed Approach 30 Auster Aircraft Elevator Trim Tab Cables 30

I

• continually adding to his knowledge those required when the crew faces unusual things which he learns from each new flight conditions. PART 1· and from accidents he may witness or hear about. He may have acquired financial, CRITICAL PEAKS DURING FLIGHT social and family responsibilities, and these, coupled with the responsibility he feels for What are the results of fatigue in air­ AVIATION NEWS AND VIEWS his crew, his passengers and his aircraft, crew? The Cambridge Studies showed that may begin to cause persistent, though un­ the effect of fatigue is greatest at the end acknowledged, anxiety. of a flight when the demands for efficient performance are at their height. It is fre­ r Such feelings of anxiety and responsibility quently necessary for the pilot to produce a are entirely normal so long as the individual rese:;:·ve of energy and capacity at the end Aircrew Fatigue can handle his problems constructively. But of a long flight in order to make an instru­ when such anxiety is unresolved, tension in­ ment approach which may be difficult. The creases. Excessive work without frequent deterioration of skill and the acceptance of 'l'he following is a condensation of a paper, "Aircrew Fatigue and Flight Time rest periods tends to affect the central Limitations", by J. N . Newton, Chief, Flight Branch of !CAO Air Navigation lowered standards noted in the Cambridge nervous system as well as bodily resistance, tests are particularly significant in relation Bureau, and is an extract from "Pilots' Safety Exchange Bulletin 56 - 107" by and it has been found that cumulative and courtesy of the Flight Safety Foundation. to overlooking landing gear switches, since persistent anxiety, coupled with inability to misuse of the landing gear is a common escape the responsibilities to which he is cause of accidents. The following is from a report by the such intensity that normal recuperation does constantly subjected, may finally result in aeroneur osis. First class vision, with particular refer­ C.A.B. regarding an air transport accident not occur, and which may result in a change ence to convergence and accommodation, is in which fatalities occurred when the plane of personality (aeroneurosis). OTHER FACTORS a primary requirement for flying personnel. crashed into the pier supporting the Fatigue can noticeably impair such visual approach lights. What causes fatigue in actual flight? acuity. It is noteworthy that in several re­ ANXIETY " ... It is believed fatigue was a factor Studies have produced many variables. The cent accidents where fatigue has been a con­ design of the aircraft itself, its size and tributing factor, visual errors (during final in this accident. It was not only present as In an attempt to discover the causes and a result of the time en route, but mostly a weight, location of instruments, the effort approach and landing) have been the results of fatigue in aircrew, a series of required to activate the controls, the noise primary errors leading to the accident. result of the additional extended hours de­ experiments (Cambridge Cockpit Studies) voted to four approaches and the high mental and vibration to which the crew is subjected, From the evidence gathered, it would appear were conducted in England, in which actual together with variants of altitude, pressure, that fatigue is cumulative and leads to a nd physical demands made upon the flying conditions were simulated as the tests pilots . . ." temperature, noxious gases and oxygen- all errors of judgment which can endanger the were in progress. These experiments were have an influence upon fatigue. Load, i.e., safety of the aircraft, its passengers and its What is fatigue? What causes it, what governed by the idea that a pilot anticipates the number of items that have to be dealt crew. are its results and what can be done to the dangers in flying and responds to such with simultaneously or nearly simul­ "anticipatory tension" with responses in­ prevent its occurrence or to minimize its taneously, is also a factor. Much depends, PREVENTIVE FACTORS effects? tended to remove the danger and so relax too, upon the duration of flight, the fre­ the tension. It was discovered that pro­ quency of the landings and take-offs, the What can be done to prevent fatigue? It is simple to define physical fatigue re­ nounced anticipatory tension can be the weather encountered and the amount of in­ Obviously, a great deal depends upon the sulting from over-exertion, but fatigue in equivalent of anxiety. str ument flying undertaken. Prolonged individual. He must maintain good physical the airman can hardly be considered solely and mental health by following a programme After long periods at the controls in these mental strain, anxiety or fear is known to a result of prolonged sustained activity. Sir result in a depleted reserve of energy. of adequate exercise (too much is as harm­ Frederick Bartlett, who has conducted a tests, a distinct deterioration in skill and ful as too little), and good and adequate number of studies, has developed a concept accuracy became apparent and the subjects, Outside influences make themselves felt in rest. He must abstain from excessive con­ of skill fatigue in which he distinguishes as they became more fatigued, were willing the regions and climatic variations through sumption of tobacco and alcohol, and follow between fatigue produced by hard physical to accept lower standards of accuracy and which flights are made, the duration of stay a healthful diet. effort and that occasioned by work demand­ performance. The range of their attention in each climate, in poor aerodromes and ing little in continuous muscular reactions diminished, with a significant forgetfulness inadequate ground services, in travel to and The operator, for his part, must do all in but much in persistent concentration and a of peripheral instruments. Landing gear from the airfields as well as such minor his power to assist his aircrew by providing high degree of skill. switches were frequently overlooked. There factors as meals at outlying stations. The good, reliable aircraft, well maintained and was a sudden increase in errors at the end amount of time spent in pre-flight duty as serviced, together with all possible ground Aircrew fatigue may be divided into two of the simulated flight, indicating that a tired well as delays in the planned flight with aids. stages : transient fatigue which is the normal airman has a tendency to relax when in sight their resultant uncertainties and anxieties In his comment on studies of pilot error, fatigue. manifest in a healthy individual of his destination. are significant contributors. Economic prob­ Dr. Russell Davis, of the United Kingdom, following a period of exertion or excitement, lems and personal worries relating to the states, "It is reasonable to expect that if and which responds to normal sleep, rest Flying is a se1·ious, responsible occupation pilot's home life also are factors in pre­ pilots come to regard flying as safe, from and freedom from such excitement; and requiring a high level of skill and intelli­ disposing him to fatigue. Pilots with nervous confidence in the conditions in which they cumulative fatigue which does not so respond gence. This degree of intelligence often or neurotic temperaments, aggravated by fly, the accident rate will decline. On these but which may occur after transient fatigue makes a pilot more conscious of his sur­ domestic troubles, cannot conduct crew co­ grounds alone, everything possible should be when an individual has undergone stress of roundings and minor discomforts. He is ordination or give the necessary confidence done to relieve pilots of anxiety about the 2 s outcome of their flights. Traffic and other pilots and operators, have all contributed approach. Fatigue is evidenced by the pilot's which caused the sinking descent before the arrangements should be such that not only towards a solution. poor adher ence to the localiser path, the last aircraft struck the pier. These factors lend are the dangers reduced, but pilots should descent to a very low altitude before the credence to the belief that the pilot's regard them as reduced. For the same sharp pull-up, and the evidence of abrupt efficiency and nor mal ability were seriously reasons, careful briefing must be regarded A CASE IN POINT control action. It may also be noted to some impaired by fatigue." as important". degree in the pilot's slow r esponse to the · (A more complete account of this accident wind shift and the probable loss of airspeed appears on page 8.) Adequate health service and counsel for "At approximately 1400 hours on an over­ emotional problems to relieve anxiety and cast December day in 1954, persons in the tension will assist the operator in keeping vicinity of Idlewild Airport, New York, were his crews at the peak of their efficiency. startled by a violent explosion followed by signs of an intense fire. Investigation re­ Avoidable Collisions on Agricultural Operations Proper scheduling so that flight time is vealed an incoming European aircraft had evenly divided, with no pilot assigned to crashed into the pier supporting the successively long and tedious flights, can do approach lights to Runway 4, had been URING the past few months there has listed below, these collisions would have been much to keep fatigue at bay. demolished by impact and had carried 26 been a large number of collisions with avoided if the proper precautions had been obstructions during agricultural opera­ observed. Instead, five pilots were injured, Ensuring adequate messing and other persons to their deaths in the icy waters of D Jamaica Bay. An inquiry was carried out tions. The investigation of these accidents two fatally, and ten aircraft substantially facilities at outlying stations and keeping reveals that in many cases, such as those damaged, four beyond repair. pm-flight duty and stand-by time to the by the Civil Aeronautics Board. minimum also will help. Furthermore, it is the operator's responsibility to ensure the "The findings provided several interesting Date Location Injuries Aircraft T ype of Accident thoroughness of all maintenance work as a and pertinent pointers on fatigue in aircrew Damage and it is proposed, in conclusion, to allow 5.10.55 Colac, Vic. Fatal Destroyed Collision with power lines during spraying series of even minor mechanical difficulties operations. can cause anxiety and uncertainty over the these facts to speak for themselves. It should serviceability of the aircraft. be noted that this aircraft carried a large 6.11.55 Horsham, Vic. Serious Destroyed Collision with tree on spraying r un. crew complement; a captain who had made 12.11.55 Canaga, Qld. Nil Substantial Collision with fence on take-off. Operators should co-operate with aircraft 150 Atlantic flights-75 info Idlewild Air­ 24.11.55 Collingullie, Nil Substantial Collision with power lines during spreading designers to achieve the best possible port, three other pilots, a radio operator and N.S.W. operations. arrangement of instruments, lighting, heat­ two flight engineers as well as a cabin staff. 2.12.55 Mareeba, Qld. Fatal Destroyed Aircr aft collided with tree at E)nd of spraying ing and other flight deck details, thus en­ It would be reasonably assumed, therefore, run. deavouring to eliminate unnecessary or that excessive duties were not undertaken by 21.2.56 Warragul, Vic. Nil Destroyed Collision with high terrain during spreading. difficult manoeuvres during flight. Aircraft any individual. However, as the Civil 21.2.56 Bowr al, Nil Minor Collision with obstruction during take-off. designers also should provide the best Aeronautics Board report states : 'Company N .S.W. possible cockpit visibility, together with such 4.4.56 Macla ren Vale, Nil Minor Collision with fence during take-off wh en full officials testified that on a normal North r un available was not used. instrument grouping as might best lessen Atlantic flight the captain and one of the S.A. the visual strain upon the aircrew. 8.4.56 Timor, N.S.W. Minor Substantial Collision with high terrain after aircraft other pilots would fly the aircraft to pr oceded too far up valley during spread­ Proper coding of cqntrols by variations in Shannon and then would rest during the ing. position, shape, colour and size might reduce Atlantic crossing while the other pilots flew 24.5.56 Stawell, Vic. Nil Minor Collision with fence during take-off. the likelihood of errors. the aircraft. After reaching the more con­ 13.7.56 Walcha, Nil Substantial Collision with f ence dur ing take-off. All these factors can help to prevent the gested areas of the United States, the cap­ N.S.W. incidence of fatigue and, together with fre­ tain would again take control until the flight 20.7.56 Boorowa, Serious Substantial Collision with power lines when returning to quent rest periods for recuperation, can do terminated. This procedure afforded each N.S.W. strip after spreading. much to avert cumulative fatigue and pilot nearly equal rest periods. The bunks 1.9.56 Mulgowrie, Nil Substantial Collision with power lines during dusting aeroneurosis. on board the aircraft provided them with Qld. operations. the best rest possible considering it would 24.10.56 Gatton, Qld. Nil Minor Collision with electric light cables during crop There has been a mistaken concept in be under flight conditions and with con­ dusting. many quarters that the only answer to air­ tinuing respective responsibilities for the craft fatigue is to lessen exposure time by flight .. .' Note: In all these accidents DH82 aircraft wer e involved. flight time limitation. Actually, the limita­ tion of flight time and corresponding "on ". . . There is no reason to believe that duty time" is only one of the many methods normal rest procedures were not followed. This list excludes those accidents where Five of these accidents are in the first that can be employed. The whole aviation It is nevertheless believed fatigue was a collision with obstacles or the ground have class, and with one exception these were due industry and its associations have been work­ to pilots not knowing the location of the ing to improve safety, regularity and factor in this accident. It was not only occurred through unwitting errors of judg­ present as a result of the time en route, ment or piloting. particular power lines. Careful ground in­ efficiency of air navigation, which in effect approximately 22-! hours, but mostly a result spection, supported by inspection from the reduces the load on the aircrew and goes a of the additional extended 2-§- hours period The collisions listed may be divided into air, prior to commencing operations in each long way toward reducing fatigue. devoted to the four approaches and the high two classes- location is absolutely essentially to avoid The problem of fatigue has received a mental and physical demands made upon the (i) Collisions with power lines, and this type of accident. Operations manuals great deal of consideration, and nations, pilots. The element of fatigue is strongly (ii) Collisions with obstructions th;:i.t the call for such inspections and these accidents principalities and powers, not to mention suggested, especially during the last aircraft could not outclimb.

4 6 prove beyond all doubt the need for this pre­ expecting more performance than it is caution. You cannot afford to assume that possible to obtain from their aircraft. All­ Serviceability of Licensed Aerodromes you know an area from your last visit; make up-weight and density altitude have a large a thorough inspection both from the ground effect on climb performance, particularly and the air before commencing each series with engines that are not supercharged. of operations. In several accidents it has Take-off runs are also effected by these (6/356/1}5) been established that pilots were unaware factors and by varying aerodrome surfaces. the maintenance of the aerodrome concerned The table hereunder on this page shows ... During the past twelve months there has that new power lines were erected since been quite a number of cases of aircraft and report any unserviceability, it is their last visit to the area. It is obvious, how the climb performance of a typical apparent that this is not always being done. agricultural DH82 varies with weight and landing on unserviceable areas at licensed therefore, that if an inspection was made in aerodromes and also of aircraft landing on Therefore, it is suggested that, in addition these cases, it was only of a very cursory density altitude. licensed aerodromes which were unservice­ to obtaining the latest available information nature. Incidentally, a density altitude of 5,000 able. on a particular licensed aerodrome, pilots feet exists at a pressure altitude of 2,000 In the second class there are nine acci­ Investigation of these incidents has re­ should make it a r ule to closely examine such dents. Basically they amount to pilots feet when the air temperature is 98.6°F. vealed that in nearly all instances the in­ aerodromes before landing. structions issued to aerodrome licensees So that we can help you, would you please 1,825 lb. 1,600 lb. All-up-weight All-up-weight regarding notification of aerodrome service­ report any deficiencies in the serviceability Density Altitude ability status and aerodrome unserviceability status of licensed aerodromes to the nearest Rate of Climb Gradient Rate of Climb Gradient markings we1·e not complied with. Regional Office. This may be done by (Feet per min.) of Climb (Feet per min.) of Climb Although an aerodrome licensee, or his lodging an incident report at any Air Traffic Sea Level 330 1: 12.5 420 1 : 9.9 nominee, is required to personally supervise Control or Communications Unit. 5,000 feet 135 1: 30.7 225 1: 18.5 Pilots, know the performance you can your aircraft will do under varying condi­ expect from your aircraft and don't just tions, then you are ill-equipped for your Help Others to Help You hope that you will clear the fence on take-off work and you expose yourself and others to or stagger over that rising ground ahead of needless and costly consequences.. Guess­ N incident summarised in this Digest ( c) Other aircraft being shuffled to pro­ you. If you are unable to determine what work can be fatal. deals with a flight from King Island to vide separation. AMelbourne where the pilot became un­ (d) Weather information on all aero­ certain of his position and requested assist­ dromes in the area of probability Use of Antihistamines ance from Air Traffic Control. However, the being obtained and passed to the pilot. pilot did not advise A.T.C. that he had re­ ( e) A navigation plot being commenced, duced power and he did not pass all changes and continued until the emergency no At this time of the year a lot of people This period of observation should cove1· at of course, times, fuel endurance or estimated longer exists. get hay fever and use antihistamine drugs to least a week because the effects are cumula­ position, and A.T.C. did not request these tive, and the checking should preferably be Provided the pilot has passed details of combat it. These drugs are also used for details. Following this incident controllers courses, times, indicated airspeeds and fuel other illnesses due to allergy. Several of done by your doctor. have been advised that where the pilot does endurance, A.T.C. has the necessary facilities them are used to prevent air sickness. Pilots According to the Air Navigation Regula­ not give these details, they shou~d requ~st to prepare a reasonably accurate plot as who have antihistamines prescribed for them tions you may not act as a crew member ~f the information and at the same time advise quickly as possible and suggest a cour ~e of should consider possible side effects, which your capacity to act as a crew member is the pilot that a plot is being established and action. The accuracy of such a plot is of vary with individuals and with different impaired by any " ... narcotic or stimulant that a D/ R position will be advised and a course dependent upon the information drugs. drug". course of action suggested. supplied by the pilot. The plot is particularly There should be no harm in operating air­ If you need to take antihistamines, it's up The investigation revealed that the pilot important in establishing the search area in craft while you take antihistamines IF­ to you to see that your fitness to fly is n~t was not fully familiar with the information the event of an emergency landing or the and it's a big "if"-you have been observed impaired by the drug. By the way, anti­ to be passed when declaring an emergency disappearance of the aircraft. for possible side effects and found to be O.K. histamines won't cure or prevent colds. such as occurred on this occasion (see AIPI These situations are most likely to occur S.A.R.) or the assistance that can be pro­ All these drugs are antihistamines :- under difficult flying conditions. In such vided by Air Traffic Control. In an emer­ circumstances A.T.C. are in the most Actidil Bonamine Histostab Pyrilamine gency such as this, the alert phase of the favourable position to make a detailed air Allercur Bromazine Longifene Pyronil emergency procedures is introduced which navigation plot and suggest courses of Ambodryl Chloroprophen- Marzine Sandosten · results in - action. But to do this A.T.C. must be in Ancolan pyridamine Menhydrinate Synopen (a) The R.A.A.F. Rescue Co-ordination possession of all the details of the flight. Andramine Maleatic Neo-Antergan Tagathen Centre being advised and search air­ The controller in charge of such a situation Andrews Chlor-Trimeton Neo-Hetramine Thenfadil craft alerted. will be a senior officer thoroughly familiar Anthisan Diatrin Perazil Thenylene (b) Ships, lighthouses and any oti:ier with S.A.R. procedures and aware of your Antistine Di-Paralene HCl Phenergan Thephorin facilities which may be able to assist, problems. He is there to help you. Help him Avil Dramamine Piriton Travamine being alerted. to help you. Avomine Histadyl Pyranisamine Vibazine Benadryl Histan tin Pyribenzamine

' '1 ... "' PART II -~ I 11 I Ii OVERSEAS ACCIDENTS %

g~• z9 !i"' e ~ ~ a ~i ~·% 0 ~ ~ Landing Accident - DC.68 - Jamaica, New York i Z f Oz• ... ~ ·~ ... f "' "' (This summary is based on the repo'rt of the "' ! Civil Aeronautics Board, U.S.A.) ~ (16/ 2/ 28) ::;., o"' T approximately 1400 hours on 18th after, weather conditions were again re­ ~.: December, 1954, a DC6B crashed into ported below minima for runway 22. They i A the pier which supported the left row were then reported as : ceiling 300 feet, of slope line approach lights to run­ broken, 2,500 feet, overcast; visibility 2t way 4 at the New York International Air­ miles, light rain and foi! : wind south-south­ port (Idlewild). The accident occurred east 20 knots. during the flight's fourth instrument ap­ While holding, the captain was asked by w proach to the airport. The entire crew of Approach Control if he would be able to rn 10, and 16 of the 22 passengers, were killed; O'. make an approach to runway 4, the ILS run­ :::> four of the six survivors received serious way, considering the tail-wind component. 0 injuries. The aircraft was demolished by 0 impact and sank in Jamaica Bay. An in­ The captain accepted runway 4 and was cleared at 1307 for an ILS approach. At O'. tense fuel fire followed the impact and 1313 the tower was advised by 451 that the w spread over the water surface and pier. N approach had been missed. J The captain was next offered, and he <( THE FLIGHT 0 accepted, a GCA (Ground Approach). This 0 The aircraft was on a scheduled flight approach was abandoned at 1324, a missed­ .J from Rome to New York with scheduled approach procedure was followed, and the rn intermediate stops. After an uneventful flight returned to the Scotland pattern. .J instrument flight from Boston, the captain At 1349 the aircraft was again cleared for I reported at 1122 to the Idlewild Approach an ILS approach, the third approach to run­ z Control as being over the Mitchell Radio way 4 and its fourth to the airport. At <( Range Station at 7,000 feet. The aircraft .J approximately 1400 the aircraft struck the IL was then cleared to enter the Scotland hold­ left pier. The impact was accompanied by ing pattern (located approximately 13 a violent explosion and followed by an in­ nautical miles south-west of the airport) tense 1h-e. Tower personnel immediately and was subsequently "laddered down" to sounded the crash alarm and initiated the number one position to approach. emergency procedures. Between 1147 and 1159 weather conditions At the time of the accident weather con­ deteriornted below the ceiling minimum of ditions were reported as: ceiling 200 feet 400 feet for landing on runway 22-the run­ overcast; visibility 2-2! miles, light rain and way then in use-and the aircraft continued I fog; wind south-south-east 16 knots. The I to hold. company minima for ILS approaches to run-· I At 1159 reported weather conditions im­ way 4 are ceiling 200 feet and visibility I I proved and the aircraft was cleared for an half mile. I approach to runway 22 using the back course I _,I of the ILS (Instrument Landing System). INVESTIGATION ·a1 At 1218 the captain reported he had dis­ ft® continued this approach. He was then issued Investigation at the accident scene dis­ missed-approach instructions and returned closed that the aircraft struck the left in­ to the Scotland holding pattern. Shortly bound pier. The pier, primarily constructed ~z z~ .....ii ii ~ -~ 8 I I

9 of heavy wooden piles, extended approxi­ The six surviving passengers were seated It was learned that before the instrument procedure is not in accord with good operat­ mately 2,000 feet into Jamaica Bay, with its at -yarious positions in the main passenger approach was started positive radio contact ing practice, and the reasons for it in this offshore end 2,530 feet from the approach cabm. Two were able to extricate them­ had been established and the flight had been instance have not been definitely ascertained. end of runway 4. The floor of the pier was selves from the wreckage and climb out on given the latest weather and altimeter in­ formation. When the aircraft broke out below the approximately 14 feet above the water level to the burning pier, but ahead of the fire overcast in the vicinity-of the outer marker, in the Bay at low tide. At the offshore end enabling them to proceed immediately t~ The fatigue aspects of this investigation the pilot possibly saw the surface of the there was a vehicular turnaround -~ .-i th safety. The others were forced into the Bay have ah'eady been mentioned in Part I of water and swamp without seeing the ap­ 1! ~1rnerous piles forming each of its fou1· and were rescued by a private boat operator this issue. proach lights and reacted quickly, pulling up corners, the tops of which were about six or helicopters dispatched by the New York The crew of the flight was qualified and into the overcast. In order to arrest the feet above the pier floor. Port Authority, the New York Police De­ ascent, or again descend to establish visual partment, and the Coast Guard. .. experienced; the captain had made 150 First contact was with the pier only a .few flights over the Atlantic, 75 of which contact, it is believed the pilot lowered the feet above the water. At impact the aircraft Recovery operations, undertaken in ex­ terminated at the New York International nose of the aircraft and in so doing got very was moving nearly parallel with the pier tremely difficult conditions, produced about Airport. low. As a result he apparently again pulled towards runway 4. The impact shattered 80 per cent. of the aircraft. The wreckage up sharply, the aircraft drifting slightly the east half of the encl of the pier, breakin'x was laid out for detailed examination the left. The ascent seemingly continued, dur­ and splintering the tops of most of the ll result of which disclosed no eviden~e of ANALYSIS ing which the aircraft- lost airspeed and piles of the south-east corner. The bulk of fatigue cracking, structural failure or. mal­ began turning right. The nose of the aircraft the aircraft wreckage then sank in approxi­ functioning of controls prior to impact. Weather conditions during the accident was then lowered and power was applied. mately 30 feet of water, mainly along the period were greatly influenced by the The landing gear was probably retracted at right side of the pier, over a distance of Examination of the components of the velocity of the surface wind. The i·esultant some time during this series of events. apprnximately 1,550 feet towa1·d shore. The landing gear and flaps indicated that at im­ turbulent mixing probably kept the ceiling These movements of the aircraft are nature of damage to the pier, its closeness pact the landing gear was fully retracted and visibility from deteriorating to near strongly supported by the testimony of the to the water, and the fact that little wreckage and the flaps were extended approximately zero. 18 degrees. surviving passengers, and the path of the came to rest near the point of impact indi­ During the first three approaches the crew aircraft as observed by the radar controller. cated the aircraft struck without an appre­ Examination of the severely damaged adhered to the established minimum altitude ciable rate of descent. ILS receiver and indicators disclosed no The final descent obviously continued until and apparently maintained some margin the aircraft was a short distance from the A propeller slash mark made by a blade evidence of malfunction or failure prior to above it. The decision to discontinue these pier but too close to avoid it. of a number one propeller was found in the impact. approaches was an exercise of the captain's centre pile at the off shore end of the pier. During the accident period a normal crew judgment when he was not entirely satisfied During the Board's investigation and This cut disclosed that the number one was on duty ia the Idlewild tower located to continue. It is believed that the tail­ analysis of this accident careful considera­ €ngine nacelle was nearly centred with that about one mile north-north-west of the wind component and windshift encountered tion was given the possible misinterpretation position i:i.nd the aircraft was slightly nose­ appro3:ch en~ of runway 4. A two-way during the approaches to runway 4 were of the approach lights or an il1usion associa­ up at impact. This propeller axis having been recordmg umt made a permanent record of important factors which influenced these de­ ted with them. Evidence regarding misin­ established made it apparent that the num­ the. transmission between flights and the cisions. Although landings were being made terpretation or illusion would be primarily ber two engine crashed into the south-east vanous control tower positions. A feature down-wind this was necessary because no the testimony of the crew. This was not corner of the pier. Comparison of the of the recorder enabled determination of the other runway was equipped with ILS available for consideration, the entire crew heights of damage marks across the end of elapsed time during and between trans­ and weather conditions prevented the use being fatally injured. The Board recognizes the pier revealed that the aircraft was missions. of runway 22. This factor also probably these as possible factors; however, from all nearly level laterally at the instant of caused the pilot to use a slower indicated the available evidence the Board was unable impact. The radar controller, located in the IFR airspeed during the last approach. · to determine whether or not the lights were room several floorn below the tower cab o·ave0 a factor. Following the initial impact the left outer Evidence indicates that on the last wing panel wrapped around the piling and radar advisories to all flights making ILS approaches. The purpose of the advisories approach the pilot began a descent before Although the entire crew was lost and shattered. The centre section of this wing intersecting the glide path and continued to actual rest periods are unknown, there is no went forward above the pier deck, destroy­ was to inform the flights of their positions as observed on radar relative to the glide descend, although repeatedly advised by the reason to believe that normal rest pro­ ing several light installations before it radar controller to level off. Altitudes cedures were not followed. It is neverthe­ veered off to the right. slope, the localizer path, and distance to touchdown. The advisories were given as a throughout the approach indicate the ILS less believed fatigue was a factor in this At initial impact the fuselage was to the responsibility of the controller at various glide path indicator would have shown a full accident. It was not only present as a result right side of the pier and thus the main intervals during the progress of the scale fly-up indication. This evidence of the time en route, approximately 22t portion of the aircraft continued on making approach. A study of the recorded advisories strongly suggests that the pilot was not hours, but mostly a result of the additional additional contacts with the pier during this was made as a phase of the investigation. attempting to follow the glide path but de­ extended 2-!-hour period devoted to the four t~· avel. . These impacts disintegrated the Its purpose was an effort to reconstruct as cided to descend until visual reference was approaches and the high mental and physical nght wmg outer panel and forward fuselage. accurately as possible the probable flight established. The pilot apparently descended demands made upon the pilots. The element During this time number three and number path of the aircraft during the last approach. below the overcast in the area between the of fatigue is strongly suggested especially four engines were torn out. As the re­ (Sec nket~h. ) Considered in conjunction outer and middle markers, probably in an during the last approach. Fatigue is mainder of the fuselage moved forward it with this study were the explanatory testi­ attempt to proceed visually below the over­ evidenced by the pilot's poor adherence to turned approximately 180 degrees and when mony of the radar controller, the observa­ cast to the runway. While attempting to do the localizer path, the last descent to a very about 1,300 feet beyond the initial impact tions of two eyewitnesses, and the testimony so, however, he may have encountered a low altitude before the sharp pull-up, and point it was moving backwards. of surviving passengers. drifting fog which was not recorded. Such the evidence of abrupt control action. It

10 11 may also be noted in some degree in the PROBABLE CAUSE waiting for the captain's order to reduce throttles instead of retracting the landing pilot's slow response to the wind shift and The Board determined that the probable power and cut switches. gear as ordered by the captain. the probable loss of airspeed which caused cause of this accident was an erratic ap­ the sinking descent before the aircraft The captain had made previous go-arounds proach which resulted in a descent to an on the same runway during his twelve years' PROBABLE CAUSE struck the pier. These factors lend credence altitude too low to avoid striking the pier. to the belief that the pilot's efficiency and piloting for the operating company. There The Board determined that the probable A contributing factor to this accident was is no reason to doubt that this one would cause of the accident was the co-pilot's normal ability were seriously impaired by pilot fatigue due to the particular and fatigue. .. have been successful had it not been for the action in closing the throttles which subse­ difficult circumstances. unexpected power interruption caused by quently resulted in the afrcraft striking a the first officer's action of closing both powerline pole. DC.3 Landing Accident - Yakima, Washington • Viscount Training Accident- Blackbushe, England (This sum11iary is based on the report of the Civil Aeronautics Board, U.S.A.) (18/27/80) (This summary is based on the report issued by the Minister of T-ransp01·t and Civil ~C . 3 w~s subs!antially damaged when over the field for not more than ten minutes. Aviation, U.K.) (18/27/85) 1t collided with a power line pole During the storm maximum gusts of 40 VISCOUNT type 701 crashed during 30 feet only had been reached, the aircraft A during an attempted go-around at knots with no windshift were noted. Eight take-off on a training flight from hit the ground. Impact was at a point some Yakima Airport, Washington State. None points of rain fell on the aerodrome in very A Blackbushe Airport, England. The 250 yards from the r unway in a steeply­ of the fifteen occupants was injured. short time, leaving the sealed runway quite aircraft sustained major impact damage and banked, nose-clown attitude. The aircraft THE FLIGHT we.t, which resulted in poor braking. fire broke out which almost completely des­ cartwheeled and slid along the ground back­ troyed it. All five occupants were slightly Whilst the aircraft was en route from The captain stated that the touch-down wards for 200 yards, coming to rest just was at an indicated airspeed of 70 knots and injured. inside the no:::·th-west boundary of the aero­ Seattle, Washington, a storm passed in the drome. vicinity of Yakima, with heavy rain on the that brakes were applied repeatedly with no THE FLIGHT airport and wind from the south. When braking effect. This created ~ definite INVESTIGATION about twenty miles north-north-west of possibility of overrun, and the captain's de­ When the aircraft was lined up on run­ cision to go around was considernd proper. way 26 the training captain, occupying the Evidence was obtained from eye-witnesses Yakima, the flight contacted the control that Number 3 propeller stopped rotating. tower, and was cleared for an approach to He advised the first officer of no braking right-hand pilot's seat, informed the pilot effect and advanced the throttles to take-off under test that he intended to simulate an One of these witnesses was a supe1·numerary runway 22. On base leg the tower reported pilot who was looking out of a cabin window. a surface wind at 10 knots from the south. power to commence the go-around. The air­ engine failure during the take-off sequence craft became airborne. at 70 knots I.A.S. which was to be purely visual. The training Not only did he see Number 3 propeller Approach clearance to runway 16 was then feather but he also noticed a sudden cessa­ requested and received and the flight path and as it passed the south end of the runway captain stated that upon reaching the V2 at an altitude of approximately 25 feet and speed of 106 knots when the aircraft was tion of noise from the starboard side of the was altered accordingly. At this time the aircraft. storm had passed to the north of the air­ an I.A.S. of 75 lmots, the captain ordered just becoming airborne, he carried out port, and the ceiling and visibility were "gear up". Instead of raising the gear the manual feathering of No. 4 propeller by the Three of the blades of Number 3 propeller well above V.F.R. minima. first officer pulled both throttles back to the three movements prescribed by the operator, were in the feathering range, whilst three· closed position. The captain testified that namely:- of the Number 4 propeller were in the fine The aircraft touched down in the first he then lowered the nose to hold airspeed pitch range. Damage to the blades indicated quarter of the runway 1,040 feet from the (i) moving the high pressure (H.P.) and re-applied full throttles. He did not land cock lever to the feather position; that Number 3 propeller was almost approach end, but a go-around was started immediately after striking the pole because (ii) pulling back the throttle lever; and stationary on impact and that Number 4 when about three-quarters of the runway of numerous cattle in the pasture. propeller was rotating. length was used. The aircraft settled to (iii) pressing the feathering button. the ground 110 feet beyond the runway end The first officer, aged 30, had accumulated The gauges showing r.p.m. and torquemeter Examination of the control cabin re­ and rolled 219 feet before again becoming a total of 3,400 pilot hours, including 1,200 pressure for No. 4 engine were checked as vealed that Number 3 H.P. cock lever was airborne. Fifty-nine feet beyond this point hours in DC.3's. He testified that he was showing zero, signifying to him that feather­ selected to the feathering position, to attain the right wing struck a powerline pole 15 not advised of the go-around and that the ing was completed. which the latch must be raised and the lever feet above the ground, tearing off portion order for gear up was the only thing said by By this time the pilot under test was moved right back through the gate. The· of the wing. The aircraft then flew across the captain after power was applied and the experiencing difficulty in maintaining direc­ other threP, H.P. cock levers were forward a half-mile wide pasture, and struck a ten­ go-around started. He stated: "At the time tional control as the aircraft was turning to of the gate. The throttles were all nearly foot willow tree. The wheels again contacted the command was given I was expecting starboard despite application of rudder and fully open but these positions were con­ the ground 55 feet beyond this tree, and the an order to reduce power and inasmuch as aileron controls. As he selected the under­ sidered to be unreliable owing to the effects. aircraft came to a braked stop after rolling it looked like a crash was inevitable- when carriage up, the training captain took over of crash damage. 575 feet. All passengers left the aircraft the order came, I moved them by spon­ control because the rate of turn was increas­ Inspection of Numbers 3 and 4 engines. safely and promptly by the stair-type cabin taneous action." The first office1"s left hand ing and the right wing was dropping. He and propellers established that Number 3 door. was resting on the control pedestal but not then noticed that the aircraft was not propeller actuating piston was in the posi­ touching the throttles as the go-around accelerating beyond 106 knots, and, believ­ tion to be expected if the H.P. cock lever· INVESTIGATION started. He estimated the aircraft's altitude ing that he would still gain control, he put had been .moved to the feathering position The storm passed over the airport from as ten feet or more above the ground when the nose down slightly in an endeavour to and the feathering button not operated. the south-west to the north-east and was near the end of the runway, and was then increase the speeq, but as a height of about Number 4 proppller piston was so positioned.

12 13 that the blades would have been in fine pitch and torquemeter pressure for Number and giving approximately 10,000 r.p.m. at 4 engine, both of which he read as bell. The captain, on the right, was per­ the throttle travel approximately one inch. the moment of impact. No functional ab­ zero. Because the engine was forming the duties of the first officer, and rearward of where the throttles normally normality was found in the Number 4 throttled right back the torquemeter he stated that at the time he had operated would be after the first power reduction. propeller feathering system. pressure would have been zero but the gear up handle and was toggling the An attempt to reconstruct the flight from the small pointer of the two pointer r.p.m. to the proper engine speed following The following observations were recorded the first power reduction. The captain, at the testimony of witnesses leads to the belief oy the investigator :- r.p.m. gauge would have been indicat­ that the aircraft banked to a near 45-degree ing 10,000. In l\i.s rapid glance at the time of feeling the aircraft yaw left, did position prior to ground contact and that ( i) Consideration of the evidence in con­ this gauge he must have misread it. not observe the zone 1 fire warning light or recovery from the bank and turn was under· junction with the operator's drill fo1· hear an alarm. However, he did observe a way at impact. manual feathering makes it apparent (iii) Movement of the throttle in the rapid drop in the left BMEP gauge, which that the training captain had moved -feathering drill on this occasion was went to zero, and he reached under the right First impact with the ground was with Number 3 H.P. cock lever (which was not necessary as watermethanol in­ arm of the first officer, then on the throttles, the tip of the left wing while the aircraft two inches longer than Number 4) to jection was not being used. The to retard the left engine mixture control to was steeply banked to its left. A study of" the feathering position instead of movement was included in the idle cut-off. The first officer stated that he wreckage and ground marks indicated that Number 4, and had then throttled feathering drill only to cut off water­ then removed his right hand from the this bank was approximately 35 degrees. back Number 4 engine and pressed methanol injection when that system throttles and reached for the manual feather­ The general direction of impact was about Number 4 feathering button. These was being used. Following this acci­ ing button, whereupon the captain informed 180 degrees or about 50 degrees to the left. actions cut off the fuel from Number dent, the operator issued instruc­ him that the automatic feathering device of the direction of take-off from runway 23 .. 3 engine and feathered its propeller tions that simulated engine failures would cause the propeller to feather. The first As the aircraft cartwheeled up a small in­ and also reduced Number 4 engine to on take-off during training flights officer then, without actuating the feather­ cline, the left wing disintegrated and the idling conditions. Pressing Number would only be made when the use of ing button, placed his right hand on the wreckage came to rest with the right wing 4 feathering button had no effect on watermethanol was unnecessary. The control column and reached forward with elevated. This resulted in fuel from the· Number 4 propeller however as the drill was altered accordingly to ex­ his left hand for the zone 2 firewall shut­ ruptured fuel tanks of the right wing flow­ H.P. cock lever was not in the clude movement of the throttle. off lever. The aircraft continued to yaw to ing clown and under the shattered fuselage, f eathering position. The aircraft was the left and stayed banked sharply to the feeding a fierce gasoline fire and quickly thus deprived of all power on its PROBABLE CAUSE left despite attempted strong corrective con­ trapping many occupants. Investigation starboard side at the moment of be­ trol. At about that time the left wing struck revealed no evidence of fire prior to impact,. The accident is considered to have been and there was no indication of a mechanical coming airborne and the situation due to an error by the training captain who the ground and the crash resulted. The was made worse by No. 4 propeller maximum altitude reached from take-off to failure prior to impact with the ground. idling in fine pitch. operated Number 3 high pressure cock lever impact was variously estimated as in the Tests of the engines propellers, and their instead of Number 4 when simulating a components did not disclose any indications (ii) The training captain believed he ha

15 moving the throttle rearward it seems more aggravated by the windmilling of the left than likely that he did so intuitively when propelle1· brought about with the captain's his attention was diverted by the fire warn­ movement of the left mixture control to ing light. the idle cut-off position. PART Ill The captain, on the right, did not see the It must be concluded that each pilot zone 1 fire warning light and only noted reacted to the emergency as he understood the BMEP gauge indicate power loss. He the emergency, but, as the two pilots had pulled the mixture to idle cut-off. The not full common knowledge of what was 1 AUSTRALIAN ACCIDENTS throttle having been retarded did not allow happening nor precisely what the other was automatic feathering, only windmilling, doing, their joint and unco-ordinated actions thus setting up excessive drag and yaw to resulted in a windmilling propeller making J the left. Since the captain attempted to the aircraft unflyable under the circum­ obtain autofeather ing by pulling back the stances. Accident to Avro Anson near Hawkstone Peak, Western Australia, on 4th mixture lever, it is apparent that he neither knew the left throttle had been retarded to PROBABLE CAUSE February, 1956 a point where autofeathering was inopera­ The Board determined that the probable (6/656/16) tive nor did he expect this action by the first cause of this accident was unco-ordinated officer. emergency action in the very short time It is believed that the yaw to the left was available to the crew, which produced an SUMMARY At 1834 hours, Wyndham aeradio i·ecorded a message from the aircraft advising that first experienced when the left throttle was airplane configuration with unsurmountable N 4th February, 1956, at approxi­ pulled aft and this yaw was violently drag. it had departed Tableland for Derby at ' mately 2000 hours, an Avro Anson 1832 hours and the estimated time interval 0 crashed 3-! miles north of Hawkstone for the flight was 100 minutes, flight level Peak, Western Austi·alia. At the time of the 4,000 feet and fuel endurance 205 minutes. accident the aircraft was under charter to At 1903 hours Broome called the aircraft the Royal · Flying Doctor Service of Aus­ and broadcast the current Derby weathe1· tralia, and was on an emergency medical but did not receive an acknowledgment. flight from Tableland to Derby, Western From this time onwards the aircraft was Australia. The occupants of the aircraft called by Broome, Port Hedland, Wyndham were the pilot, a sick child, her father and and Derby aeradio stations at regular inter­ two nurses. All the occupants were killed vals but without success. Radio calls to in the accident. homesteads in the area on the Flying Docto1· THE ACCIDENT frequency failed to obtain any reports of the On 1st February, the medical practitioner aircraft and Wyndham advised Darwin at the Derby Hospital was advised by radio Traffic Control of the circumstances. Subse­ of the child's illness. Despite treatment, her quently the Distress Phase was declared and eondition deteriorated, and on 3rd February a search was commenced the following morn­ arrangements were made to fly her to Derby ing. On the 22nd February, eighteen days Hospital. However, a sudden improvement later, the wreckage was located 3-! miles caused these arrangements to be cancelled north of Hawkstone Peak. before the aircraft left Derby. The improve­ ment was sustained until 1500 hours oii the THE SEARCH following day, 4th February, when a relapse -occurred and it was decided again that she The search was one of the most intense must be transferred to Derby as soon as operations of this nature conducted in Aus­ possible. tralia for missing aii·craft. In its closing stages it was conducted in the face of The Anson was fuelled to capacity and it extremely bad weather. departed Derby at 1625, arriving at Table- 1and at 1814 hours after an uneventful It opened, on the morning following the flight from its base at Derby, 185 miles disappearance of the aircraft, with a away. The route and terminal forecast for R.A.A.F. Lincoln and a DC.3 searching in the flight from Derby indicated that the the immediate vicinity of the track of the weather throughout the flight would be aircraft. At the end of this first day there 5/8ths Cb. Cu. cloud with a base of 5,000 to was no result, but a large number of re­ 7,000 feet, isolated thunderstorms, visibility ports were received from residents who 15 miles, reduced to six miles in thunder­ believed they had either heard or seen the I storms, and wind below 5,000 feet from the missing aircraft along the track, along a south-west at 14-16 knots. line roughly from Derby to Wyndham or

lG I 17 in the general area of Wyndham. The re­ probability of the signal source, it was search with the Department's DC.3's and the ports in the Wyndham area appeared to be p~·oven beyond doubt that the mystery signal Proctor based at Glenroy. On the second so definite that on the following day, the did not come from the missing aircraft. day of the operntions by these aircraft the available aircraft were divided, some By this time eight days had passed and w1·eck of the Anson was located a few miles searching along the track and others search­ crews and aircraft had been subject to such to the north of its track and in the foothills ing in the Wyndham area. On the third concentrated fl ying that it was decided to of the King Leopold ranges. The wreck lay day all aircraft were concentrated in the i·est all crews and make a complete review about 15 miles nor th of Kimberley Downs Wyndham area because the initial interro­ of all available information. Accordingly homestead, separated from that aerodrome gation of some of those who reported sight­ the various author ities working in the by three rivers in flood and with most of ing the aircraft in this area seemed to indi­ search joined together at Darwin. All re­ the intervening country covered in water. cate that it had diverted to Wyndham at por ts of sighting or hearing the aircraft Never theless, a land party assembled at some time during its flight to Derby. Mean­ were sifted and only one was accepted as Kimberley Downs, and equipped with rub­ time supporting aircraft of the Department authentic-that from Mount House, a home­ ber dinghies, made a difficult journey to the of Civil Aviation had joined the R.A.A.F., stead about half-way along the track. The wreckage over a period of 2~ days. It found who had now increased their force to three whole area of probability had been searched no survivors, but identified the wreckage as Lincolns and a Dakota. Additional airline to the degree which satisfied the authorities that of the missing Anson and then returned aircraft were also chartered by the Depart­ that a reasonably whole Anson was nowhere to Kimberley Downs. ment to assist' in tlie search. With this large in it. It was therefore decided to concen­ force of aircraft an extensive area based on trate on the track between the last sighting THE INVESTIGATION the Wyndham sighting reports was searched, position and Der by. This area except for At the time the land party visited the while teams from the R.A.A.F., the Depart­ the last 30 miles, comprised the r ugged King scene of the accident it was not possible to ment, and the Western Australia Police in­ Leopold ranges. On the 10th day a search conduct a thorough examination of the vestigated each report of sighting or hearing of a saturation type using Lincoln aircraft wreckage. For this pur pose a further expe­ of the aircraft and then discussed their find­ was carried out in this area, but with no dition was made late in April a t the con­ ings at Wyndham. At the end of this fourth success. The reports of the crews indicated clusion of the wet season and all important day these teams were satisfied that 'none of that the speed of their aircraft would make components of the aircraft were recovered the reports of the aircraft having been seen it difficult to see wreckage in the deep from the ground and examined. or heard in the Wyndham area had any valleys. It was therefore decided to base a The aircraft virtually disintegrated on foundation and it was decided to switch the fleet of light aircraft at the Glenroy impact and the wr eckage was confined to a search aircraft back on to the track area Abbatoirs backed with the two DC.3's from r elatively small area. It was apparent from and the general surrounds of Derby. the Department and with ground parties the impact marks, wreckage distribution It was while this action was taking place equipped with Land Rovers and radio equip­ and nature of the damage that the aircraft that a carrier signal with the characteristics ment. The R.A.A.F. aircraft were with­ had struck the ground in an almost vertical of an Anson transmitter was heard by drawn from the search. attitude at a high speed. It was established stations over a wide area throughout Aus­ The action with the light aircraft was that both engines were operating at the tralia. The signals were intermittent with planned to be completed in four days but in time of the accident. All the components short unintelligible bursts of keying. Some fact it took 10 days due to the interference of the airframe were located at the wreckage HF/ DF bearings were taken and they indi­ of a cyclone, and was then never carried site but it was impossible to ascertain the cated that the probable source of the signal out to the original plan. As the organisa­ serviceability of these components imme­ was in the area around Wyndham. The tion was assembled at Glenroy a cyclone of diately prior to the accident because of the search authorities meantime had learned considerable intensity developed, isolating extensive damage they sustained. that the Anson was carrying food and fruit, the advance party at Glenroy, where the The pilot held a third class airline trans­ and this, along with the signal being heard) aerodrome and camp area were flooded to a port pilot licence, a second class instrument created the possibility that there were depth of four inches; the light aircraft were rating, and a second class flight radio­ survivors who could hold out for a period marooned at Port Keats and Wyndham on telephone operator licence. His total aero­ and who were trying to draw attention of successive days. nautical experience amounted to 4,830 hours, the search forces to their position. After attempting for three days to get of which 203 hours had been flown as pilot This possibility suggested that the Anson the light aircraft in, all except one, a Proctor in command of Anson aircraft. He had was not extensively damaged and should be .aircraft which had gone with the advance flown regularly in Western Australia since found somewhere in the search area. There­ party, were withdrawn from Wyndham to 1949 and was fully familiar with the area fore for the next three days, using all avail­ Darwin during the midday period of fine in which the accident occurred. able aircraft, the entire area of probability weather which usually occurs during The weather was substantially as fore­ calculated on the distance the Anson could cyclonic conditions in that. area. Afte1· cast, fine at Derby, Mount House and Table­ fly with the fuel it was carrying, was saturating the country with rain for six land, with a line of thunderstorms extend­ searched. Meantime every effort was made days the centre of the cyclone moved from ing in approximately a north-south direte­ to track down the mystery signal, and at over the search area to a few miles east of tion about half-way between Mount House last, by generating a signal from an identical Derby and the weather over the search area and De1·by, i.e., at right-angles to the track set in another Anson located in the area of improved. It was decided tO continue the of the aircrnft. The base of the thundel'-

18 19 storm clouds was forecast to be 5,000 feet On arrival at Tableland, the pilot was above mean sea level, which is about 2,000 faced with the decision to continue or probable cause of the accident was that It is the policy of the Department to feet above the highest tenain along the terminate the flight, having regard to the the aircraft encountered a thunder­ recognise that pilots in command of mercy route. These clouds, associated with the safety of the aircraft and occupants on one storm of such severity that control of flights may depart from prescribed safety inter-tropic front, would i·each their hand, and the condition of the patient who the aircraft could not be maintained. standards whe1·e this is necessary to save maximum peak of activity shortly after sun­ was requiring urgent medical attention on (h) A contributory cause of the accident some person from grave or imminent danger. set. This activity, which is normally of the other. In view of the weather and was an error of judgment on the part In exercising this discretion pilots sl1ould short duration, results in a lowering of the limited navigational aids in the aircraft, it of the pilot in attempting the flight carefully assess the risks involved to ensure cloud base, squalls of considerable severity is now apparent that the return flight sub­ under the existing weather conditions. that the exposure of human life to danger below the cloud and extreme turbulence in jected the five occupants to grave hazards (i) The pilots decision to attempt the flight is not being increased beyond the level that the cloud. Myroodah Homestead, 55 miles which the purpose of the flight did not was undoubtedly influenced by a strong would exist if the flight were delayed until south of the scene of the accident, reported justify. The pilot was undoubtedly in­ humanitarian concern for the patient. more favourable conditions prevailed. gale force winds, which uprooted trees, fluenced by strong humanitarian concern for shortly before 1930 hours. During the the patient, but it is believed that he made examination of the wreckage, a number of an error of judgment in deciding to continue Ryan Forced Landing - Bankstown, N.S.W. trees in the vicinity were found to be up­ the flight and this was a probable contri­ (6/255/463) rooted evidently by a storm and it is probable butory cause of the accident. HEN the engine failed on final ap­ The total fuel carried at the commencement that this storm occurred on the night of the The conclusions of the investigation in­ proach, the pilot of a Ryan S.T.M. accident. of operations was 15 gallons and seven cluded the following:- Wwas forced to land among trees about circuits and landings were carried out p1·ior The aircraft, a Mark 1, Avro Anson, was (a) The aircraft departed Tableland at twenty-five feet short of the western bound­ to the aircraft departing for Penrith. equipped with a full instrument flying panel, 1832 hours, at the beginning of night, ary of the Bankstown Aerodrome. The pilot navigation lights, fluorescent instrument and passenge1· suffered minor injuries and The engine and fuel system were and the weather along the route,. examined but no fault which could account lighting and command radio equipment. It particularly in the vicinity of the scene the aircraft was extensively damaged. was also fitted with a manual radio compass for the engine failure was found. The dura­ of the accident, comprised extensive· The aircraft departed from Bankstown tion of flying was 1 hour 50 minutes, in used in conjunction with the low frequency thunderstorms of unusual severity. receiver. However, the aircraft did not meet for Penrith, but after travelling about ten addition to a period of running-up prior to the Department's equipment requirements (b) The aircraft was restricted to flight miles the engine faltered and the pilot commencing the flight. Throughout this for instrument flight mainly because it did under visual flight rules conditions by decided to return to Bankstown. On the re­ time the engine was operated entirely on the not have duplicate pitot-static operated the terms of the operator's charter turn journey the engine faltered occasionally main fuel supply of 13 gallons and it could instruments, duplicate gyroscopic instru­ licence. and during the final approach for landing, be expected that on the basis of consumption ments, or adequate navigation aids. (c) The aircraft was fitted with a full when at a height of about 200-300 feet and rate of 7 gallons per hour, this fuel would some 600 yards from the aerodrome, the be exhausted about the time the engine From the distribution of the wreckage instrument panel, cockpit and naviga­ tion lights, two-way radio communica­ engine cut out and picked up twice before failed. and the nature of damage to it, it appeared failing completely. The pilot then concluded that the aircraft struck the ground when t ion and a manual radio compass but At the time of the accident, the main fuel did not meet the minimum equipment that the trouble was fuel starvation and supply was exhausted. Therefore the out of control. There was no evidence of selected "reserve" fuel, but the engine disintegration in flight and in view of the requirements prescribed by the Depart­ amount of fuel remaining could not have stopped rotating before fuel could reach the exceeded 2 gallons, the capacity of the "re­ extreme severity of the storm, through ment for operations under instrument engine. which the aircraft was flying, in the vicinity flight rules. serve" supply. The amount of fuel necessary of the accident, it can only be concluded ( d) The pilot held a current third class. The pilot was committed to a landing to provide the reserve of 45 minutes, re­ that the pilot lost control whilst endeavour­ airline transport pilot licence and a. among trees on the approach area and the quired by AIP /RAC-1-7, is 6 gallons; it is ing to fly · on instruments in extreme second class instrument rating but was aircraft struck the top of a 15 feet high tree apparent that on departure for Penrith the turbulence. No evidence was found which not authorised to act as the pilot in com­ located a short distance outside the aero­ fuel was less than the minimum required, in any way conflicted with this conclusion. drome bounda1·y and came to rest in a nose in contravention of Air Navigation Regula­ mand of an aircraft on a flight under tion 226. However, it is possible that other factors instrument flight rules. clown attitude wedged between two trees. could have contributed to the pilot's inability It was concluded that:- (e) Radio communication with the aircraft In this aircraft the fuel is contained in to maintain control, such as erratic airspeed was poor throughout the flight primarily The cause of the accident was that, and altimeter readings arising from the one tank of 19 gallons capacity. Two gallons having failed to realise that the fuel due to extremely high atmospheric noise of this .fuel are held in reserve by a stand­ effect of heavy rain on the pitot head, loss and apparently due to the failure of the supply in use was exhausted, the pilot did of the gyroscopic instruments as a result pipe outlet and are available for use by not select the reserve supply in time to pilot to transmit on CW. The last mes­ placing the cockpit fuel selecto1· to "reserve". of the aircraft being thrown into attitudes sage from the aircraft was received at keep the engine operating. beyond the toppling limits of these instru­ 1832 hours, immediately on departure ments, momentary blindness from lightning from Tableland. Helicopter Take-off Accident, New Guinea flashes, etc. Although these possibilities are conjectural, th'e possibility that some circum­ (f) The flight planned altitude did not pro­ (6/455/46) stance beyond the pilot's control contributed vide a terrain clearance of 1,000 feet BELL 4 7D helicopter was extensively to his inability to maintain control of the as required by Air Navigation Regula­ the tail rotor pitch control cable. The pilot, tion 157 (1). damaged at Morehead heliport, New who was the only occupant, was uninjured. aircraft is indicated by the manner in which A Guinea, when it crashed almost im­ The pilot tested the tail rotor controls it hit the ground with the engines under (g) CAUSE: Having regard to conclusions mediately after taking off for a test flight during the pre-flight engine run-up and, as power. (a), (l~}, (c} and (d) above th~ following replacement of the aft section of subsequent events show, he wrongly con-

20 21 l rotor blades but he failed to recognize that It was concluded that:- A contributory cause of the accident was eluded that they were functioning prope~· y. the system was operating in the reverse that the pilot neglected to carry out a proper In fact the cable had been crossed durmg The cause of the accident was that the cockpit check when the fuel pressure began installation resulting in the flight contro~s sense. to fluctuate shortly after take-off and so operating in the reverse sense. As the hel~- Prior to the accident it was a common pilot failed to select a fuel tank with a safe failed to determine that an empty fuel tank copter lifted from the landing platform. it belief of pilots of the operating c?mpany quantity of f uel fm the take-off. was selected to the engine. ' commenced to turn right, the turn steadlly that correct functioning of ~he tail rotor developed into a violent rotation as left con- could be determined by operatmg.the control Fatal Chipmunk Accident - New Park Siding, New South Wales trol, which would normall~ have coi;rected pedals during the pre-fhght e?-gme run-up, the situation, was progressively applied. which, on a float equippe~ hehco~ter on the (66/ 197/ 6) At the same time, as the h~licopter was ground produces a rockmg motion. How- Na December afternoon a DHC-1 Chip­ of positive control by ailerons is required to drifting away from the landmg platf?rm ever s~lch a check will only confirm th~t a munk crashed in a large open field at maintain laterally level flight when inverted, towards nearby buildings the pilot decided pitch change is taking place and determma- 0 New Park Siding, 17 miles south-west. it appears most improbable that there was to attempt a landing. In so doing the port tion of the sense of operation of the system of Narrandera, New South Wales, during any jamming or obstruction of aileron con­ float fouled the landing platform and the is not certain. The pilo~ follow~d the ac- recovery from inverted flight at a low alti­ trol which would have either forced the pilot aircraft tipped over on its left side. . cepted practice during his pre-flight. check tude. The pilot and his sister, who was a to maintain inverted flight or prevented him The pilot .held a yalid commercial hel~- and it is considered that m so doi.ng he passenger in the aircraft, were killed in­ half rolling to the normal attitude. A half copter pilot hcence with a total of 424 homs took what were considered at that time to stantly and the aircraft was destroyed. roll can be executed in the DHC-1 with little on helicopters. be reasonable precautions to ensure that the The aircraft was engaged on a private or no loss of height at speeds very little The investigation revealed that a new aircraft was safe for flight. flight in the vicinity of the pilot's home. above the stalling speed. cable had been installed and connected by an The cause of the accident was that. the After taking off the aircraft climbed to 1,000 It is evident that the half loop from the engineer inexperienced in .helicop~ers . Later senior engineer, in carry~ ng out a functional feet, and the pilot performed a loop, half inverted position was not the result of a he was joined by a semor eng·meer, who check of the tail rotor pitch control system, roll and full roll in rapid succession. The stall caused by jamming or obstruction of completed the locking of the turnb~tckl e con- failed to detect that the control cable had aircraft then circled to a height of 1,500 feet elevators because 180 degrees of a loop were nections and made other final adJ_ustme~ts . been installed in such a maner as t?. re~erse where it was looped into the inverted atti­ completed in the space of 300 to 500 feet The control pedals were operated m spec~fic the sense of operation of the directional tude. Inverted flight in a glide was main­ indicating that considerable elevator control sequence whilst the senior engineer carne~ tained until a height of approximately 300- ·was applied. out a check of the pitch change of the tail flight controls. 500 feet, where the pilot appeared to attempt to regain normal flight by pulling under in There is no evidence to suggest that the Norseman Forced Landing: Minj, New Guinea the second half of a loop. This was almost manoeuvre was not intentional and it was (6/455/69) completed when the aircraft struck the therefore concluded that:- hours, of which 562 hours had _been flown on ground just as it gained the level flight (a) The accident was caused by the pilot HORTLY before midday, a No rsem_a~ Norseman aircraft in New Gumea. attitude. attempting to recover from inverted taxied to the south-east end of MmJ The pilot was the holder of a pr ivate pilot flight by means of a half loop when S airstrip, New Guine~, preparatory t? An examination of tl~e ::i-ircraft. revealed licence with a total aeronautical experience the aircraft was too close to the departure on a cha!ter fhght to qg~ l beng, no defects or malfunctionmg w?-ich ~ould ground. have been responsible for the engme failure. of 17 4 hours of which 36 hours had been New Guinea, 28 miles _west of MmJ . The flown on Chipmunk aircraft. (b) By engaging in aerobatic flight below pilot stated that he carrie~ ~mt a pre-t~ke-?ff However, the fuel selector was f?tmd turned to the starboard fuel tank, ~~ich was un­ The engine of the DHC-1 Chipmunk will below 3,000 feet the pilot acted in engine run-up and cockpit check, which m­ contravention of Air Navigation cluded selecting the port fuel tank for ~ake­ damaged and in such a posit10n that fu~l not deliver power in sustained inverted flight off. The weather was fine with unrestricted could not have drained away after tl!-e acc~­ which must, therefore, be a glide. As a degree Regulation 131 (3) (a) and 124 (2). visibility. dent; this tank was empty. Further mvesb­ gation revealed that 50 gallons of fuel had Fatal Auster Accident The aircraft took off into the north-west been placed in the port tank and 25 gallons (6/ 255/ 99) and soon after becoming airborne, wI?-en in the starboard tank prior to. departure climbing power had been set, the pilot from Goroka for Minj, and the aircraft had HE weather was fine with little cloud left. However, whilst still at a low altitude, noticed a drop in fuel pr e~sure. and as a been operated on the starboard tank for when a pilot and four passengers took the nose of the aircraft dropped, the aircraft result turned back to the airstrip. At the some 60 minutes. The normal fuel con­ T off in an Auster from Forbes aerodrome. entered a spin and crashed in the college same time he operated the hand fuel pump; sumption of a Norseman aircraft is 24-.26 Approximately 35 minutes l~ter the aircraft grounds 600 feet east of the main building. however whilst still some distance the f~·om gallons per hour and as this was the quantity stalled and crashed into the grounds of the The flight was conducted so that a passen­ airstrip 'the engine failed and the pilot was of fuel in the starboard tank on departure Marist Brothers Agricultural College, 2t committed to a landing in a s:wamp. The ger could take ph'.)tographs. In addition, from Goroka, very little . would h!lv.e re­ miles south of Forbes, New South Wales. All three boys were given a free "joy flight"; aircraft contacted the ground with the star­ mained in the tank on arrival at MmJ. the occupants were killed on impact. board wing and engine simulta~eou sly, and as two of them were seated on the floor cartwheeled; it was broken mto several The pilot did not realise that th e fuel Statements from eyewitnesses revealed adjacent to the rear seat, they could not be provided with seat belts. pieces and the pilot, t~e sole_ occ~p~nt ~ was selector was turned to the e!llpty starboard that the aircraft was observed at a height thrown clear and received mmor mJuries. tank. Despite the pilot's b ~hef that he car­ just above tree tops flying straight and level The aircraft was a standar d Auster J5 r ied out a "normal cockpit check before towards the college. As it neared the college, "Autocrat" fitted with seats for a pilot and The pilot held a senior commer~ial pil~t take-off it is clear that this check could not licence and at the time of the accident his the pilot commenced a climbing turn to the two passengers; the certificate of airworthi- total flying experience amounted to 7 ,466 have been properly conducted. 28 22

• The all-up-weight was approximately 50 Auster Collides with Tree whilst Spraying ness restricted the number of persons to be lb. below the maximmn permitted and the carried to three. The pilot was the holder of centre-of-gravity was at or near the aft (6/355/380) a commercial pilot licen~e and a cur:r:ent "Bl" flight instructor ratmg. An examma­ limit. HILST engaged in the aerial spraying hours of which 1,000 hours had been flown tion of the wreckage revealed no pre-crash of a tobacco crop in a field three miles on Auster aircraft. His flying experience ,on defects or evidence of malfunctioning. It was concluded that:- W west of Mareeba, Queensland, an aerial agriculture operations totalled 31 hours all of which had been flown in the It was ascertained that the aircraft (a) The probable cause of the accident Auster J 5/B struck a tree and crashed. The approached the college at a height of between was loss of control at a low altitude pilot, the sole occupant, was killed instantly preceding 90 days. 150 and 250 feet. A climbing turn was com­ due to poor technique in the execution .and the aircraft was destroyed. The examination of the aircraft did not menced at a relatively slow airspeed and of a steep climbing turn. The field, situated in flat terrain, was ap­ reveal any pre-crash defects or evidence of proximately rectangular in shape, running malfunctioning. although power was possibly increased, the The pilot engaged in unauthorised pilot made t~o steep a cli~bing turn for the (b) east-west, some 1,150 feet in length and 600 The height, and proximity to the field, of airspeed available. The_affcraft stalled and flight at a height lower than 500 feet feet wide. It was bounded on the southern the trees significantly reduced the area of entered a spin at an altitude too low for re­ above the ground in disregard of Air .side by a road and surrounded on the other the crop that could be sprayed at the best covery to be effected. Navigation Regulation 133 (2). three sides by trees 30 to 60 feet high. The spraying height. Thus in an endeavour to weather was fine with nil wind and un­ obtain the maximum spray coverage, the Overloaded DH.84 Crashed at Togoba, New Guinea restricted visibility. pilot apparently made his approaches close to the trees, then descended steeply to the (6/455/65) The first spraying run was carried out 17 feet inside the southern boundary from west optimum spraying height and subsequently climbed out of the field at the maximum DH.84 carrying a pilot. and three pas­ ising operations in both directions with a to east. The succeeding runs were made on maximum all-up-weight of 4,200 lb. for a parallel tracks 34 feet north of the previous climb gradient of the aircraft as close as sengers and a quantity of freight possible to the trees near the end of of the crashed, immediately after take-off, DH.84 taking off into the north. The actual runs. On the fourth run, made .into the west, A weight on this take-off was therefore 320 the approach was made over a 60 feet high i·un. The spraying run in which the accident approximately one mile north of the northern occurred was made towards trees higher end of the Togoba airstrip, New Guinea. The lb. in excess of that permitted, and calcula­ tree adjacent to the eastern boundary of the tions indicate that under the prevailing field. After passing over this tree the air­ than on previous runs. Assuming that the pilot was killed .a~d ~he three . passengers aerodrome surface and meteorological con­ .craft descended to a height of approximately previous climb out of the field was made as received serious mJuries; the aircraft was close as possible to the trees, the climb on rendered a total loss by damage sustained on ditions this aircraft could not have reached seven feet above the crop which was 4 to 5 the maximum flying speed in the length feet high, and a spraying run was carried this run would need to be commenced earlier impact. of strip available using the optimum tak~­ out at this level. As the aircraft neared the to clear the trees. As the pilot was relatively Togoba airstrip is situated between. the off technique with full power. It is western boundary it commenced to climb to inexperienced in aerial agriculture operations Turuk and Nebilyer Rivers in the Nebilyer apparent from the circumstances o~y1e take­ dear the trees immediately outside the fence; it is possible that, whilst attempting to ob­ Valley West ern Highlands, New Guinea. It off that the aircraft was "bounced mto the however, the port wing struck a 54 feet high tain the maximum spray coverage, he failed is a single airstrip running ~pproximately air and height could not be maintained in tree, at a point 11 feet from the top. The to appreciate the increased height of the north and south, 4,000 feet m lengt~ and this condition even with full power. After w ing passed through the tree but almost trees on this run and commenced the climb 200 feet wide, with a clay surface hghtly leaving the airstrip the height of the aircraft immediately afterwards the aircraft rolled from the same position as on the previous grassed. above the ground was insufficient to enable to the left and then descended on a steadily run. The aircraft was on a charter flight . to the pilot to lower the nose in an endeavour steepening turn to the left. The aircraft The probable cause of the accident was Wabag New Guinea, and was loaded with to gain the airspeed to climb.aW3:Y. continued in this manner until it struck a that the pilot, when attempting to climb the 670 lb.' of freight and three passengers who The pilot held a commercial licence and second tree and then crashed to the ground. aircraft at a steep angle in close proximity boarded the aircraft at Togoba. The all-up­ the last entry in his log book, which had not The pilot held a commercial pilot licence. to the tree, misjudged the distance from the weight of the aircraft was ~,520 l~.. ~.he been maintained for the five years prior to His total flying experience amounted to 3,017 tree at which to commence the climb. weather was fine, with unrestricted visibility the accident, indicated that he had flown a and wind from north northeast at 15 lmots total of 5 077 hours mostly on DH.84's. He as the pilot taxied to the southern end of had been 'engaged as a pilot on commercial Fatal Aerial Spraying Accident - Collision with Power Lines the airstrip. operations in New Guinea since September, (6/ 155/ 451) The aircraft took off after travelling three­ 1947 and was recognised as the most ex­ quarters of the length of the strip but settled peri~nced pilot on DH.84'~. in th.at counti;y, HE failure of the pilot to inspect field being sprayed was approximately rect­ back onto the ground several times befo~e and was particularly familiar with the air­ thoroughly the intended area of low angular in shape, lying in a northwest­ passing over the northern end of the strip strips in the area in which the accident Tlevel operations prior to the commence­ southeast direction, 2,000 feet by 1,000 feet, some 10 to 20 feet above the ground. After occurred. ment of operations, resulted in a fatal fenced and bounded at the south eastern end accident in a field at South Dreeite, 10 miles by a road. Running along the opposite side leaving the air~trip the aircraft ~ommenced It was concluded that:- to lose height mto the Turuk River Valley northwest of Colac, Victoria. of the road to the field is an electric power and a few moments later it crashed into The cause of the accident was the attempt The aircraft, a DH.82, was engaged in the line on 30 feet high poles, 500 feet apart. relatively thick vegetation approximately by the pilot to take-off at an all-up-weight aerial spraying of a property at South A line of trees approximately 20 feet high one mile north of the northern end of the in excess of that at which a take-off could Dreeite. The terrain in the vicinity is un­ was immediately below the power lines. strip. be successfully executed under the existing dulating with large outcrops of granite The weather was fine with scattered At the time of the accident, operations at aerodrome surface and meteorological r ising 20 to 30 feet above the ground. The cumulus cloud, nil wind and unrestricted Togoba were g·overned by a NOTAM author- conditions. 25 The pilot held a student pilot licence and pilot misjudged his height in relation to the visibility. The ah-craft made two low level clear the wires by a small margin, theref ore had accumulated a total of 43 hours experi­ ele.ctricity cables. it appears that he failed to see them, at ence, all in DH.82's, during the preceding circuits of the field and then carried out a 90 days. The limited experience of the pilot and spraying r un along the northeastern side of least, until he was dangerously close to them. the small dimensions of the field are con­ the field. The spray runs were made at a The pilot held a .commercial pilot licence The cause of the accident was that the sidered to have contributed to the accident. height of about 7 to 8 feet above the ground with a total·tlying experience of 1,450 hours. but as the aircraft neared the end of the His experience on agriculture operations Collision with Power Lines second r un, which was being made towarda amounted to 30 hours, all of which had been t he road, it passed over a granite outcrop accumulated in the 90 days preceding the (6/255/185) a bout 20 feet higher than the road. The accident . HE failure of the pilot of a Cessna 180 juries and the aircraft was damaged beyond aircraft continued to fly straight and level It was concluded that the cause of the to inspect the area of low level opera­ repair. and struck the electric wir es on the south­ accident was that the pilot failed to Ttions was the probable cause of a col­ The pilot was the holder of a commercial eastern side of the road. The pilot was killed thoroughly inspect the intended area of low lision with electricity transmission cables instantly on impact with the ground and the pilot licence and had extensive experience level operations to ascertain the nature and spanning the Clarence River, 26 miles north­ in aerial agricultural operations. His total ah-craft was destroyed. location of obstructions. west of Grafton, N.S.W. aeronautical experience amounted to 5, 775 Eyewitnesses reported that the aircraft By failing to familiarize himself with the hours of which 230 hours had been flown on appeared to be functioning normally during operating area prior to commencing opera­ The aircraft was engaged in distributing Cessna 180 aircraft. After the accident he spraying r uns and prior t o the impact the tions, the pilot disregarded a requirement fertilizer on flats bordering the river. was unable to recall any of the events about aircraft was flying straight and level. As of the operator's approved operations Electricity cables crossed the river suspended the time of the accident, even from the time the spraying r un had been completed, ther e manual, contrar y .to Air Navigation Regula­ from 45 feet high pylons on rising ground he boarded the aircraft. He had flown on was no necessity for the pilot to attempt to tion 212 (6) . about 80 feet above the water level. Due to fertilising operations in this locality some ·sag, the cables came to within 100 feet of the 12 months previously and he stated that he flats being top-dressed. Large trees formed Collision with Wires near Maffra, Victoria an effe.ctive camouflage against detection of should have remembered these power lines the pylons from a low flying aircraft, and but had apparently forgotten them. (6/.155/470) t he cables were not readily discernible It was concluded therefore, that the cause against the background of timber and un­ of the accident was that the pilot did not DH.82 engaged on a pilot navigation high tension wire, a DH.82 could be landed dulating terrain. inspect the area of intended low level training flight, crashed and burnt after in the space available. operations to ascertain the nature and Astriking high voltage electl'icity cables On this spreading run the aircraft main­ location of obstructions and thereby deter­ located along the leeward boundar y of a At the time of the attempted landing there tained a constant height until it struck the mine a safe height for the operation. It is field in which a landing was being attempted was overcast low cloud, but the visibility is cables, when it slewed to the left and dived absolutely essential to the safe .conduct of after the pilot had become lost . The pilot, considered to have been adequate. The pilot to the ground. The port tailplane, elevator, this type of operation that the operating who was the only occupant, suffered serious determined the wind direction then executed fin and r udder were severed by the cables areas should be carefully examined both injm·ies including severe burns. The air­ an approach r un over the field for inspection and dropped off the aircraft before it struck from the ground a nd the air and operations craft was destroyed by fire which started purposes during which he noted the cables the ground. The pilot suffered serious in- based on such inspections. immediately on impact with the ground. across the approach path. On the second approach, from which it was intended to Seven aircraft departed Moorabbin for land, the under.carriage struts struck the West Sale, a distance of 114 miles. A few cables and the aircraft plunged to the light showers over the route with a sub­ ground in a nose down vertical attitude 80 stantially overcast sky, base 4-5,000 feet, feet beyond the cable alignment and came were forecast. Six of the air.craft reached t o rest in a vertical position. the destination without incident but the pilot of the other aircraft became uncertain of Because of the serious injuries sustained his position after flying through a heavy by the pilot, his evidence was relatively shower and decided to land. brief and incomplete. It was not ascertained The field selected was approximately 1,200 whether he had the electricity cables in f eet long in the direction of intended land­ sight during the final approach but it appears ing and had along the leeward boundary a that he did, but misjudged his height. The row of timber poles spaced about 300 f eet limited run available in this field required apart carrying high voltage electricity cables that touchdown be made as short as possible at a height of about 20 f eet above the and therefore, the cables would need to be ground. The field itself was approximately crossed with the minimum clearance. The 300 feet shorter than the minimum for a pilot saw the .cables when making the pre­ DH.82 prescribed in AIPI AGA-4, and its liminary approach and, as there is no in­ effective operational length was further re­ dication of a deterioration in visibility duced by 'the presence of the elevated elec­ occurring between the two approaches, it is tricity cables across the approach. However, considered that the aircraft collided with it was the most suitable field in the locality the cables because the pilot misjudged his and it is probable that, after cleal'ing the flight path. 27 26 The pilot in command of the aircraft held assist to any appreciable extent in the a first class airline transport pilot licence, a operation or navigation of the aircraft. PART IV first class instrument rating and a flight radio telephony operator licence. At the time It is apparent that this incident arose of this incident his total aeronautical ex­ through the pilot reading the track of Ol6°M INCIDENT REPORTS perience amounted to 2,700 hours, the majority of which had been accumulated as shown on the flight plan, as ll6°M. Shortly a first officer on DC.3's. His total experience after take-off the aircraft entered cloud and the pilot was concentrating on instrument on Doves was approximately 475 hours, all flying and maintaining the heading of the Incorrect Heading of which had been flown as pilot in com­ mand. In the four months preceding the aircraft by reference to back bearings on (6/156/265) the King Island N.D.B. The aircraft was incident he had flown on an average 67 fitted with a Pioneer type compass which is hours a month and in the seven days pre­ read through a small window. This type of ceding the incident 7 hours 45 minutes, all DOVE departed King Island (Bass proceed to Melbourne and on instructions compass does not show all the points of the Strait) for Melbourne via Moorabbin from Air Traffic Control climbed to 5,000 on Dove aircraft. However, for some months this pilot had been occupying an adminis­ compass at one time and is not fitted with Aat 1630 hours on the 19th May, 1956, feet. However, after checking his probable a grid ring. That is, the heading of the air­ carrying a crew of two and nine passengers. position on a map he estimated that there trative position and these duties in addition Moorabbin, 18 miles south-east of Melbourne was now insufficient fuel on board to reach to his flying duties had imposed an excessive craft in relation to other points of the com­ airport, is the normal entry point into the Melbourne and at 1714 hours he turned onto work loading on him. He has stated that at pass is not readily noticeable and there is Melbourne Control Zone for aircraft ap­ a course of 300°M for King Island aerodrome no pre-setting required. proaching from the south, and the track from and reduced power to conserve fuel. The the time of this incident he was in a fatigued King Island to Moorabbin is Ol6°M and the pilot then plotted his position on the map condition. The hostess, who held a commer­ distance is 128 miles. On this occasion the by "dead reckoning" using the . forecast cial pilot licence and had a total of 275 Whilst this incident was caused by the estimated flight time from King Island to winds and estimated that his position at hours aeronautical experience, was mainly pilot flying the wrong course, it is con­ Melbourne was 68 minutes and the fuel 1730 hours was 83 miles, 311 °T from Devon­ concerned with radio operator and hostess sidered that fatigue was a contributing endurance on departure was 139 minutes. port. He calculated that from this position duties on this flight and was not able to the time interval to reach Devonport would factor. On departure from King Island the pilot be at the most 30 minutes and that he would set course for Moorabbin Aerodrome on a have 45 minutes fuel in reserve on arrival track of ll6°M, which was flown by back at Devonport. At 1730 hours he set course bearings on the King Island non directional on 120°M for Devonport and shortly after­ beacon (N.D.B.). There was very little wards the Devonport N.D.B. was received drift and the course flown to make good this on the radio compass. A landing was made track was also l16°M. The weather over at Devonport at 1820 hours. Bass Strait at the time was generally 5/8ths to 7 /8ths cloud with a base of 500 feet and Immediately the aircraft requested assist­ Information Breakdown: Communications Breakdown tops 5,000-8,000 feet. Shortly after reaching ance, Melbourne Air Traffic Control intro­ cruising altitude, 3,000 feet, at which time duced the alert phase and this activated the the aircraft was in cloud, the pilot endeav­ Rescue Co-ordination centre and opened the oured to tune the radio compass to the HF/ DF station at East Sale. The aircraft (6/156/215) Moorabbin and Melbourne N.D.B.'s, but was instructed to climb to 5,000 feet to en­ without success. The pilot states that "at sure terrain clearance, other aircraft were approximately 1709 hours (i.e., 39 minutes kept clear of the probable position, all HORTLY after departure from Mel­ frequencies after departing Melbourne Air­ after departure) I became suspicious of the aeradio stations in the vicinity were alerted bourne Airport on a regular public port. This aircraft was unable to establish fact that neither N.D.B.'s (Melbourne or and a plot was commenced. The information S transport service, the crew of a DC.3 radio contact on H.F. and returned. Moorabbin), 3LO (a Melbourne broadcasting supplied by the pilot concerning changes of station) or the V.A.R. (Melbourne) were courses, times and indicated airspeeds was found that they were unable to establish radio contact with aeradio on the V.H.F. being received. I then checked my course meagre and resulted in the plot giving a Investigation revealed that the radio against the flight plan and discovered that very large area of probable position. Before frequencies. Subsequently, contact was estab­ engineer had changed the channel selections I had made an error of 100° in my heading Air Traffic Control obtained the information lished on H.F. and the flight continued. (i.e., proper heading Ol6°M) ". necessary to estimate a reasonably accurate on the aircraft's V.H.F. equipment but had position, the pilot i·eported that he was omitted to advise the company operations He immediately advised Melbourne Air altering course for Devonport. The aircraft On the following day the crew of another staff that this work had been carried out and Traffic Control of the circumstances and re­ was then provided with the latest weather DC.3, owned by the same company, were also consequently both crews were unaware of· information, at that aerodrome and advised quested assistance. At almost the same time the changes. he turned onto a course 350°M intending to of its facilities. unable to contact aeradio on the V.H.F. 29 28 again. The buffeting appeared this time to easily scared or inexperienced pilot into a emanate from the tailplane region. Tlie con­ force_d (or imagined forced) landing onto Tractor and Roller Cause Missed Approach trol column was pushed slightly but firmly unsmtable or dangerous terrain with resul­ forward and again after 2 or 3 seconds the tant danger to aircraft and occupants." (6/356/186) buffeting stopped and the aircraft cruised norm ~ll y. The pilot realized that the prob­ The opinion expressed in the last para­ "straight in" approach was made, the driver able cause of the buffeting was that with graph is endorsed. REGULAR public transport DC.3 on a the trim tab control lever resting in a nose­ 'straight in" approach to Runway 09 did not notice the aircraft until it had com­ menced its missed approach. down position it left the nose-up wire slack Investigation by the Department of this A at Longreach aerodrome observed a allowing the trim tab to move from its tractor and roller on the runway and carried and other similar incidents resulted in the Longreach is non-controlled. In order to streamlined position behind the elevator and out a missed approach. :fl.u tter or oscillate between almost fully following letter being forwarded to all assess the se1·viceability of the r unways and nose-up and nose-d?wn positions, tending to Auster afrcraft owners in July this year. The driver of the tractor had been notified other factors affecting the safety of the move the elevator m the opposite sense. It of the estimated time of arrival of the air­ aircraft, a circuit or partial circuit should seen~ed that certain attitudes of the tailplane craft. However, the aircraft arrived some to air flow and/or to the twisting and beat­ seven minutes ahead of its estimated time always be carried out at non-controlled aero­ dromes. ing propeller slip stream may have caused and for this reason and the fact that a the slack trim tab to fluctuate or flutter rapidly up and down, occasioning the alarm­ ing buffeting and control column movement Auster Aircraft Elevator Trim Tab Cables aforementioned. Accordingly the trim tab control lever was moved to a position just AUSTER ELEVATOR TRIM TAB CABLE: on the nose-up side of neutral, taking-up the (6/256/312) sl'.'1-ck in t!ie no~e-up wire and putting a INSPECTION shght stram on it, thus preventing the tab N recent years there has been a number control column, and this pressure was re­ from fluttering into the nose-down position. of Auster aircraft elevator trim tab duced to an almost negligible amount by a Should it now flutter it must do so only in Dear Sir, I cable failures during flight, both in this slight reduction of power to normal cruising a restricted way in the nose-up part of its country and in New Zealand. The following r.p.m., and the movement of some of the travel and in the airstream only on the underneath side of the elevator (likely to be Recently two Auster accidents have report was submitted by a pilot of an Auster luggage to a position further forward in the occurred because of elevator trim tab aircraft on the failure of the elevator trim rear compartment. more constant than the airstreams it ex­ perienced alternating from underneath to cable failures. One happened in Queens­ tab cable during a flight from Mt. Margaret land, the other in New Zealand. Station in South-west Queensland to Bourke, The flight continued normally for about above the elevator). N .S.W. in May this year. 10 minutes until the aircraft was turned In the first case a successful landing above a possible landing ground to inspect The flight to Bourke continued unevent­ was made with great difficulty but in the "It was a clear calm day and the aircraft it. Several steep turns in both directions fully with the trim tab control lever ill the New Zealand case, control was lost and made a normal take-off and climb to 1,000 were made normally until a fairly steep neutral position and over Bourke aerodrome the aircraft crashed with the loss of the feet. The passenger sat in the front seat, banked. turn (about rate 3) was made to the a series of turns, steep and gentle, and life of the pilot and his two passengers. and about 150 lb. of luggage was in the rear left during which a well-defined, alarming climbs steep and gentle, failed to reproduce and almost violent buffeting of the whole any semblance of the buffeting or control of the cabin ; the tanks were full. At the An investigation into the circumstances completion of the climb as the elevator trim aircraft was experienced, coupled with a column movements experienced earlier when rapid back and forward shaking movement the trim control lever had been in a nose­ of the Australian accident revealed that tab control lever was moved to a more nose­ due to the unavailability of correct cable, down position the nose-down wire broke of the control column (covering a distance down position. of about 4-5 inches travel). the heart strand of 5 cwt. flexible cable near the trim tab itself. The trim control had been used for both top and bottom lever, though it could still be used to get The reason for doing the turns and climbs trim cables. Diameter of the substitute nose-up trim by use of the still-intact nose­ Immediately this buffeting and shaking was to establish that the position of the cable was approximately .035 in. as com­ up wire to the bottom of the trim-tab, was commenced maximum power was applied, trim control lever was the factor which, pared with .048 in. in the case of the slack and useless in the nose-down half of the aircraft was r eturned to a level attitude coupled with the broken nose-down wire to original cable. The substitute cables had its travel, owing to the broken nose-down and within 2 or 3 seconds the untoward the trim tab, caused the almost violent buffet ­ been in operation for 560 hours since wire, and was left in a position about ! way manifestations ceased and normal flight was ings and control column movements ex­ installation and had last been inspected round to fully nose-down, though this continued in the direction of Bourke; the perienced earlier. 67 hours prior to the failure. Excessive position had no effect on the trim tab itself aircraft climbed satisfactorily to 3,000 feet. wear and corrosion reduced the strength which merely streamlined itself with the However, with 1950 r.p.m. and 80 m.p.h. It is the writer's opi:i;tion that these buffet­ of the cables to such an extent that they elevator. Nose-up trim could, if desired, I.A.S., and the aircraft in a slightly nose-up both failed. This caused the aircraft to still be obtained with the lever per medium attitude with the wings level in the rolling ings, if unchecked, might perhaps cause more severe structural damage to elevators shudder violently and made it exceedingly of the intact nose-up wire. plane, the stick was being moved gently difficult to control even with reduced forward to round off the climb for level or elevator controls, make landing very difficult, or even if experienced for only a power. The pilot made an emergency The nose-down trim could easily be held cruising when the same pronounced buffeting landing. by a slight hand pressure forward on the and control column fluctuation were evident short time with no damage, precipitate an 31 30 In the case of the New Zealand accident, the exact type of cables fitted to your air­ the aircraft had flown 362 hours 25 minutes craft at present, the hours they have been in since overhaul (1,257 hours total time). The service and the details of all previous replace­ .- accident followed failure of the upper trim ments, i.e., size, construction and hours at tab cable about 4! in. from the trim tab replacement. attachment. The break occurred at the point where the cable is subjected to heavy friction It is strongly recommended that you have the elevator trim tab cables of your aircraft ... where it passes into the fairlead. Examina­ - tion of the broken cable showed that ex­ inspected as soon as possible and periodically cessive wear had obviously taken place prior at inte1·vals of not more than 25 flying hours to the accident. until further notice. Your attention is also drawn to the fact Would you please ensure that no 'im­ that last year another Auster accident occur­ .. provised' trim tab cables are fitted to your red because of a trim tab cable failure aircraft. Any such cables should be replaced brought about by sticking of the trim tab ... I by solid piano wire or correct cables. arm pivot. This caused excessive bending of the cable and resultant failure. Our records indicate that solid piano wire used as trim tab cables on a large number of In performing the inspection we recom­ Austers appeared to have a very much better mend that the cables be inspected at full service life than stranded counterparts. We trim tab movement in both directions and are informed however, both solid and cables showing any signs of wear, flat spots stranded trim tab cables need to be replaced or broken strands be replaced before further periodically. In order that we can make a flight. It is also essential to ensure complete • proper assessment of the problem we would freedom of the pivot pin referred tq above". like to have full case histories of trim tab • cable replacements and would therefore You will be notified further of any other • appreciate if you would kindly advise us of information of interest which we obtain.

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