16 October 2008, VH-WRT, GA-8 Airvan GA-8 2008, VH-WRT, October 16 Northern Territory, Missing aircraftBay, Buckingham ATSB TRANSPORT SAFETY REPORT Aviation Occurrence Investigation AO-2008-072 Final Missing aircraft Buckingham Bay, Northern Territory 16 October 2008 VH-WRT, GA-8 Airvan AO-2008-072.indd 1 8/07/10 11:21 AM ATSB TRANSPORT SAFETY REPORT Aviation Investigation AO-2008-072 Final Missing aircraft Buckingham Bay, Northern Territory 16 October 2008 VH-WRT, GA-8 Airvan Released in accordance with section 25 of the Transport Safety Investigation Act 2003 - i - Published by: Australian Transport Safety Bureau Postal address: PO Box 967. Civic Square ACT 2608 Office location: 62 Northbourne Ave, Canberra City, Australian Capital Territory, 2601 Telephone: 1800 020 616, from overseas +61 2 6257 4150 Accident and incident notification: 1800 011 034 (24 hours) Facsimile: 02 6247 3117, from overseas +61 2 6247 3117 Email: [email protected] Internet: www.atsb.gov.au © Commonwealth of Australia 2010. This work is copyright. In the interests of enhancing the value of the information contained in this publication you may copy, download, display, print, reproduce and distribute this material in unaltered form (retaining this notice). However, copyright in the material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly. Subject to the provisions of the Copyright Act 1968, you must not make any other use of the material in this publication unless you have the permission of the Australian Transport Safety Bureau. Please direct requests for further information or authorisation to: Commonwealth Copyright Administration, Copyright Law Branch Attorney-General’s Department, Robert Garran Offices, National Circuit, Barton, ACT 2600 www.ag.gov.au/cca ISBN and formal report title: see ‘Document retrieval information’ on page v - ii - CONTENTS THE AUSTRALIAN TRANSPORT SAFETY BUREAU ................................ vi TERMINOLOGY USED IN THIS REPORT .................................................. vii FACTUAL INFORMATION.............................................................................. 1 Sequence of events ........................................................................................ 1 Witness information ........................................................................... 3 Pilot information ............................................................................................ 7 Aircraft information ....................................................................................... 8 Maintenance history ........................................................................... 9 Fuel on board ..................................................................................... 9 Aircraft and fuel weight and cargo weight ........................................ 10 Meteorological information .......................................................................... 12 Wreckage and accident site information ....................................................... 13 Operator’s procedures .................................................................................. 16 Flight over water .............................................................................. 16 Flight notification ............................................................................ 16 Radio settings on departure .............................................................. 16 Load security ................................................................................... 17 Dangerous goods ............................................................................. 17 Additional information ................................................................................. 18 Aircraft loading................................................................................ 18 Alternate loading method ................................................................. 20 Centre of gravity and controllability of the Airvan............................ 20 Departure information and radio calls............................................... 23 Bush fires on the Napier Peninsula ................................................... 25 Reconstruction flights ...................................................................... 25 ANALYSIS ........................................................................................................ 27 Sequence of events ...................................................................................... 27 Pilot fatigue ................................................................................................. 27 Airworthiness and maintenance .................................................................... 28 Aircraft fuel ................................................................................................. 28 Restraint of cargo in the cabin and aircraft centre of gravity ......................... 28 Radio calls ................................................................................................... 28 - iii - Observation of 'dark black smoke' ................................................................ 29 Summary ..................................................................................................... 30 FINDINGS ......................................................................................................... 31 Contributing safety factors ........................................................................... 31 Other safety factors ...................................................................................... 31 SAFETY ACTION ............................................................................................ 33 Aircraft operator .......................................................................................... 33 Loading and cargo restraint .............................................................. 33 Flight following ............................................................................... 34 Carriage of dangerous goods ............................................................ 34 Management supervision and oversight ............................................ 35 Reduction of pilot workload ............................................................. 35 Other actions.................................................................................... 35 APPENDIX A: Search information .................................................................. 37 Northern Territory Police/ATSB search effort .............................................. 37 Elcho Island Community search ................................................................... 39 APPENDIX B: RECONSTRUCTION FLIGHTS ........................................... 41 First reconstruction flight ............................................................................. 41 Second reconstruction flight ......................................................................... 42 APPENDIX C: GA-8 AIRVAN LOADING TRIM SHEET ............................ 43 APPENDIX D: GA-8 AIRVAN CARGO NETS .............................................. 45 Main vertical cargo net ................................................................................ 45 Baggage shelf net ......................................................................................... 45 Throwover net ............................................................................................. 46 Aft luggage bin net ...................................................................................... 46 APPENDIX E: SOURCES AND SUBMISSIONS ............................................ 47 - iv - DOCUMENT RETRIEVAL INFORMATION Report No. Publication date No. of pages ISBN AO-2008-072 July 2010 50 978-1-74251-078-1 Publication title Missing aircraft - Buckingham Bay, Northern Territory - 16 October 2008 - VH-WRT, GA-8 Airvan Prepared By Reference Number Australian Transport Safety Bureau ATSB-Jul10/ATSB109 PO Box 967, Civic Square ACT 2608 Australia www.atsb.gov.au Acknowledgements Figures 1, 2, 4, 5 (part) 6, 8, 23, A-1, A-2 and B-1: Google Earth. Cover photo, Mission Aviation Fellowship Abstract On the morning of 16 October 2008, a Gippsland Aeronautics GA-8 Airvan, registered VH-WRT, was being operated on a freight charter flight from Elcho Island and return, Northern Territory. At about 1230, it was realised that the aircraft was missing. A witness reported seeing the aircraft during the early stages of the flight and, shortly afterwards, a column of dark black smoke rising from the eastern side of the Napier Peninsula. On 17 October 2008, items of wreckage from the aircraft were found in the south-western part of Buckingham Bay. The pilot, who was the sole occupant of the aircraft, and the main wreckage of the aircraft have not been found. After consideration of the available evidence, the investigation was unable to identify any factor that contributed to the accident. Although the investigation did not identify any issues that had the potential to adversely affect the safety of future operations, the operator took proactive safety action in response to the accident. That action included changed procedures in the areas of cargo restraint and the carriage of dangerous goods, the supervision and oversight of flights, and to the operator’s flight following requirements. In addition, the operator has acted to