Accident
On 7 May 2005, at 1143:39 Eastern Standard Time, a Fairchild Aircraft Inc. SA227DC Metro 23, registered VH-TFU, impacted terrain on the north-western slope of South Pap, a heavily timbered ridge in Iron Range National Park, approximately 11 km north-west of Lockhart River aerodrome. The aircraft was operated by Transair on an instrument flight rules (IFR) regular public transport service from Bamaga to Cairns, with an intermediate stop at Lockhart River, Queensland. On board were two pilots and 13 passengers. The aircraft was destroyed by impact forces and an intense post-impact fire. There were no survivors.
Approach and Weather
The crew was conducting an area navigation global navigation satellite system (RNAV (GNSS)) non-precision approach to runway 12. Weather conditions in the area were poor, with a cloud base estimated between 500 ft and 1,000 ft above mean sea level. The terrain to the west of the aerodrome, beneath the approach path, was probably obscured by cloud.
Flight Data and Wreckage
Flight data recorder (FDR) data indicated that throughout the descent and approach, engine and flight control system parameters were normal, and the crew accurately navigated the aircraft along the instrument approach track. The aircraft was configured for landing with gear down and flaps at half. No radio broadcasts indicated any problems with the aircraft or crew.
Investigation Findings
The investigation concluded that the accident was almost certainly the result of controlled flight into terrain. Contributing factors included: the crew commenced the approach despite the copilot lacking the appropriate endorsement and experience; descent speeds and rates exceeded those in the Transair Operations Manual; the aircraft descended below the segment minimum safe altitude; the crew did not detect or correct these deviations; high workload and loss of situational awareness; the pilot in command had a history of similar non-compliant operations; the approach design itself increased workload; the copilot had no formal training for the approach; Transair's training, supervision, and operational procedures had significant limitations; Transair had not installed a terrain awareness and warning system; organizational structure issues; and Civil Aviation Safety Authority (CASA) guidance and oversight deficiencies.