Incident Overview
At about 1500 hours EST on 11 June 1993, a standard company flight plan for Piper PA-31-350 aircraft VH-NDU was activated. The plan indicated flight OB 301, a regular public transport service from Sydney (Kingsford Smith) airport to Cootamundra NSW, with intermediate landings at Cowra and Young. The flight was planned under IFR procedures with a scheduled departure of 1720, crewed by two pilots. Prior to departure, the company scheduled a second aircraft for the Sydney–Cowra sector, so VH-NDU was only required to land at Young and Cootamundra. At that time of year, the 1720 departure meant the flight would be conducted entirely at night.
Flight Progress
VH-NDU departed Sydney at 1738 with five passengers and fuel endurance of about 253 minutes. The pilot-in-command occupied the left seat. The aircraft initially tracked via the direct Sydney to Cowra route and climbed to 8,000 feet. At 1801 the pilot reported to Sydney FIS that the aircraft was now tracking direct to Young, and would report at Riley, an en route reporting point 62 NM from Young on the Katoomba–Young track. FIS advised the area QNH was 1003 hPa. At 1814 the pilot reported being at Riley and estimated arrival at Young at 1835. By 1820 the pilot reported descent to Young with in-flight conditions of cloud and heavy rain. Recorded radar data later showed the aircraft passed 13.5 NM south-east of Riley, south of the direct track. At about 18.5 NM north-east of Rugby, the aircraft turned right and initially tracked about 280° before turning left to track direct to Young. At 1836 the pilot amended the estimate for Young to 1838. At 1842, after prompting from FIS, the pilot reported at Young that he was commencing an NDB approach and would call again on the hour or in the circuit.
Accident Sequence
Shortly after 1845 witnesses at Young aerodrome saw the lights of an aircraft, believed to be VH-NDU, pass low overhead after approaching from the east. Some minutes later the same aircraft was seen to pass over the aerodrome from the opposite direction and appear to climb away towards the east. On both occasions the runway and aerodrome lights were not illuminated, although the aerodrome was equipped with PAL and it was the pilot-in-command's responsibility to activate it. At 1850 FIS advised VH-NDU of the proximity of Cessna 310 VH-XMA, estimating arrival at Young at 1900. VH-XMA subsequently reported holding in visual conditions about 8 NM north of Young. The pilot of VH-NDU reported at 1903 that he was on another overshoot at Young, about to commence another approach, and would report again at 1915. FIS provided additional traffic on Piper PA31 VH-XML, also estimating Young at 1915. About this time witnesses reported seeing the runway lights illuminate. VH-XMA landed on runway 01 at about 1912. At 1916 VH-NDU reported in the Young circuit area and cancelled SARWATCH. A pilot witness said the aircraft passed over the northern end of the aerodrome from a westerly direction before turning right onto a heading consistent with a right downwind leg for runway 01. The aircraft then turned right and passed south of the aerodrome before entering what appeared to be a right downwind leg for runway 19. When abeam the aerodrome, it again turned right and overflew the aerodrome to enter a second right downwind leg for runway 01. Another witness thought VH-NDU was significantly lower than VH-XML approaching from the east. Shortly after VH-NDU turned onto an apparent base leg, the navigation lights were lost to sight. Almost immediately a fireball was observed, consistent with the final position of the aircraft.
Emergency Response
At 1918 the pilot of VH-XMA telephoned 000 and reported the accident to Goulburn Ambulance Control Centre. By 1920 this information was relayed to Young Ambulance Service, Young Police, and Young SES. An off-duty Fire Brigade officer driving into Young alerted the Fire Brigade at 1930. Emergency services initially went to Young Aerodrome but could not immediately access the accident site, which was on a hill 2.2 km south-south-east of the aerodrome, remote from roads and lighting. Access was finally gained from a road south of the site. An ambulance reached the wreckage at 1952 and crew rescued and resuscitated the only survivor, who was critically injured, and transported her to Young Hospital. She died at Camperdown Children’s Hospital at 0510 the next morning.
Probable Cause
The official findings listed significant factors: 1. The cloudbase in the Young circling area was below the minimum circling altitude, associated with dark night conditions and limited ground lighting. 2. The workload of the pilot-in-command was substantially increased by the effects of aircraft equipment deficiencies, with a possible consequent degrading of his performance as a result of skill fatigue. 3. The instrument approach and landing charts did not provide the flight crew with terrain information adequate for the assessment of obstacle clearance during a circling approach. 4. The Monarch operations manual did not provide the flight crew with guidance or procedures for the safe avoidance of terrain at Young during a night-circling approach. 5. The aircraft descended below the minimum circling altitude without adequate monitoring of obstacle clearance by the crew. 6. The visual cues available to the flight crew were insufficient as a sole source of height judgement. 7. There were organisational deficiencies in the management and operation of RPT services by Monarch. 8. There were organisational deficiencies in the safety regulation of Monarch RPT operations by the CAA.