2 fatalities

1995-09-16: Swearingen SA227 Metro III (VH-NEJ) — Tamair — Tamworth, Australia

Tamworth, AustraliaTakeoff (climb)

On September 16, 1995, a Swearingen SA227 Metro III (registration VH-NEJ) operated by Tamair was involved in an aviation accident near Tamworth, Australia during takeoff. 2 people were killed. Investigators recorded the probable cause as: 1. There was no enabling legislative authority for AIP (OPS) para. 77. 2. CASA oversight, with respect to the company operations manual and specific guidance concerning night asymmetric operations, was inadequate. 3. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781207698Data APIEditorial standards

During a Metro III type-conversion training flight, a V1 cut exercise at night led to the aircraft striking trees and crashing. The check-and-training pilot performed the cut; the co-pilot lost control. Factors included inadequate oversight and pilot experience.

Introduction

On 16 September 1995, two company pilots were undergoing first officer type-conversion training on the Metro III aircraft. Both had completed ground school training the preceding week. A company check-and-training pilot, returning from two weeks leave, was to conduct the conversions. The three pilots met at the airport at approximately 1530 EST. Over the next 2.5 hours, the check-and-training pilot instructed on daily inspections, emergency equipment and procedures, and cockpit drills, including engine failure actions. The briefing did not include detailed discussion of aircraft handling after engine failure on takeoff. After a meal break, the flight departed Tamworth at 1852, about 40 minutes after last light. The night was very dark with no moon; Tamworth city lighting was the only significant visual feature.

Flight Sequence

The trainee in the right seat performed the takeoff, his first in the Metro III. Over the next 30 minutes, he executed climbing, descending, turning, and engine handling exercises; no asymmetric flight was conducted. The check-and-training pilot then talked him through an ILS approach to runway 30R with an overshoot and landing on runway 12L at 1940. After clearing the runway, the aircraft held on a taxiway for 6 minutes with engines running. The crew discussed the next flight. The check-and-training pilot stated he would give the co-pilot a V1 cut. The co-pilot objected, questioning the legality of night V1 cuts. The check-and-training pilot replied that the company operations manual had been changed to permit it. The co-pilot made a further objection. The check-and-training pilot then said they would continue for a VOR/DME approach and asked the co-pilot to brief him. The crew discussed the approach, then received clearance to operate within a 15-NM radius below 5,000 ft. They briefed for a runway 12L VOR/DME approach, planning to reconfigure after the V1 cut.

Accident Sequence

The aircraft commenced takeoff roll at 1957.05. About 25 seconds after brakes release, the check-and-training pilot called "V1" and less than a second later "rotate." The aircraft became airborne at 1957.32. One second later, the check-and-training pilot reminded the co-pilot to maintain a 10-degree nose-up attitude. After 3 more seconds, he retarded the left engine power lever to flight idle. Over the next 4 seconds, the magnetic heading changed from 119° to 129°. The co-pilot and then the check-and-training pilot called that a positive rate of climb was indicated. The landing gear was selected up 15 seconds after becoming airborne; the landing gear warning horn sounded at about the same time. After 19 and 30 seconds airborne, the check-and-training pilot reminded the co-pilot to hold V2. Three seconds later, he said the aircraft was descending. The warning horn ceased about 1 second later. The aircraft had gradually yawed left from heading 129° through runway heading 121° to 107°. After 35 seconds airborne, it struck a tree approximately 350 m beyond and 210 m left of the upwind end of runway 12L. The aircraft rolled rapidly left, severed power lines, struck other trees, and collided with the ground inverted, sliding about 70 m. The aerodrome controller saw the aircraft become airborne but then looked away; shortly after, all lighting in the tower and on the airport failed, and flames were visible to the northeast. Emergency services were called.

Probable Cause

The following factors were reported: 1. There was no enabling legislative authority for AIP (OPS) para. 77. 2. CASA oversight, with respect to the company operations manual and specific guidance concerning night asymmetric operations, was inadequate. 3. The company decided to conduct V1 cuts at night during type-conversion training. 4. The check-and-training pilot was assigned a task for which he did not possess adequate experience, knowledge, or skills. 5. The check-and-training pilot gave the co-pilot a night V1 cut, a task which was inappropriate for the co-pilot's level of experience. 6. The performance of the aircraft during the flight was adversely affected by the period the landing gear remained extended after the simulated engine failure was initiated and by the control inputs of the co-pilot. 7. The check-and-training pilot did not recognise that the V1 cut exercise should be terminated and that he should take control of the aircraft.