6 fatalities

1993-09-17: Piper PA-31-350 Navajo Chieftain (VH-WGI) — Hibiscus Air — Launceston, Australia

Launceston, AustraliaLanding (descent or approach)

On September 17, 1993, a Piper PA-31-350 Navajo Chieftain (registration VH-WGI) operated by Hibiscus Air was involved in an aviation accident near Launceston, Australia during landing or approach. 6 people were killed. Investigators recorded the probable cause as: The following findings were reported: 1. The actual weather at Launceston at the time of arrival of VH-WGI was significantly worse than forecast. 2. The pilot did not have the required recent experience to conduct either an IFR flight or an ILS approach. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781209623Data APIEditorial standards

On 17 September 1993, a Piper PA-31-350 (VH-WGI) crashed at Launceston Airport during a visual approach. Six occupants received fatal injuries; the pilot and other occupants were seriously injured. The aircraft was destroyed by fire.

Background

A group of football club members planned to travel to Launceston via light aircraft. Three aircraft were hired from an operator at Moorabbin Airport: a Piper PA-23 (VH-PAC), a Piper PA-31-310 (VH-NOS), and a Piper PA-31-350 (VH-WGI). The organizing pilot, who also worked as an instructor for the operator, was to fly VH-WGI. On 17 September 1993, the pilot performed pre-flight inspections, obtained weather forecasts, and submitted flight plans for all three aircraft. The flight plan for VH-WGI specified a cruise altitude of 9,000 ft, a track via Wonthaggi and Bass to Launceston, a total flight time of 90 minutes, and endurance of 155 minutes. No alternate aerodrome was nominated. The estimated time of departure was 1730 local.

Flight and Communication

VH-WGI departed Moorabbin at 1817 and climbed to 9,000 ft. The pilot missed the required position report at Wonthaggi at 1832, and Melbourne ATC unsuccessfully attempted to contact him. The radar controller noted the aircraft deviating left of track but could not establish communication. At 1858, the pilot re-established contact, stating he had experienced a radio problem. The heading was corrected to regain track.

At 1927, the pilot contacted Launceston Tower and was cleared for a DME arrival along the 325 radial of the Launceston VOR. The ATIS reported 2 octas of cloud at 800 ft, QNH 1,012 hPa, wind 320° at 5–10 kts, temperature +10°C, and runway 32 in use. At 1930, the ADC advised the pilot that the cloud was clear of the inbound track but that lower cloud was forming north of the field, possibly on track. The ADC informed the pilot that if not visual by the VOR, he should perform an ILS approach via the Nile locator beacon.

Approach and Accident

At 1933, the meteorological observer reported 7 octas of cloud at about 800 ft based on a searchlight check. At 1935:52, the pilot reported at 12 DME and 3,300 ft. The ADC advised deteriorating conditions, with probably 4 octas at 800 ft. The ADC instructed the pilot to make a missed approach if not visual by the VOR, track to Nile, and climb to 3,000 ft. At 1939:45, the pilot reported at 1,450 ft and 2–3 DME, still in IMC.

At 1940:56, the pilot stated he was overhead the field but not visual and was going around. At 1941:07, he reported the field in sight and at 1941:16, positioned above final approach for runway 32. At 1941:31, he reported opposite the tower and was cleared for a visual approach or missed approach to Nile. The pilot chose the visual approach. At 1941:48, he acknowledged. No further communications were received.

Witnesses observed the aircraft emerge from cloud over the aerodrome at 500–800 ft, track southeast, then turn left to a north-westerly path northeast of the main runway. It initiated a left turn onto a close downwind leg for runway 32, descending during the turn. During the base turn at 300–500 ft, the aircraft briefly entered cloud. Engine noise was loud. On late left base leg, the aircraft was in a steep left bank (about 60°) at approximately 200 ft. It descended rapidly, struck a powerline with the right wing about 28 ft AGL, causing an airport power failure at 1943:02. Simultaneously, the left wing struck bushes. The aircraft then struck the ground and slid to a stop. A fire broke out and was quickly extinguished by airport fire services.

Aftermath

Six occupants received fatal injuries; the others, including the pilot, were seriously injured.

Probable cause

The following findings were reported: 1. The actual weather at Launceston at the time of arrival of VH-WGI was significantly worse than forecast. 2. The pilot did not have the required recent experience to conduct either an IFR flight or an ILS approach. The operator's procedures did not detect this deficiency. 3. The pilot's inexperience and limited endorsement training did not adequately prepare him for IFR flight in the conditions encountered. 4. The CAA did not specify adequate endorsement training or minimum endorsement time requirements for aircraft of the class of the PA-31-350, particularly in regard to the endorsement of inexperienced pilots. 5. An absence of significant decision-making training requirements contributed to the poor decision-making action by the pilot who decided to continue with a visual circling approach at Launceston in conditions that were unsuitable for such an approach. 6. As a consequence of continuing the approach, the pilot subjected himself to an overwhelming workload. This was due to a combination of adverse weather conditions, his lack of training and experience in IFR approach procedures on the type, and a misinterpretation of (or non-compliance with) the AIP/DAP-IAL instructions, a combination which appears to have influenced the pilot to fly a close-in, descending circuit at low altitude. The carriage of alcohol-affected passengers may have also added to the level of difficulty. 7. Because of workload, and possibly also due to distractions, the pilot inadvertently allowed the aircraft to enter a rapid descent at a critical stage of the approach, at an altitude from which recovery could not be effected.