Air Safety — Footballers’ Flight Ends in Tragedy

By 2.30pm some of the passengers, together with friends who had come to see them off, began arriving at the flying school. Finding they had time to kill, some sat down inside the building, while others stayed outside, looking at aircraft parked nearby and kicking a football about. Their demeanour was noisy and boisterous, so much so that the pilots who were to fly the Navajo and the Aztec told the young instructor they only wanted to carry passengers who “would not be noisy”. His response was that “there weren’t any”, but agreed to carry “the noisiest” in the Chieftain himself. Two particularly boisterous passengers, waiting inside the flying school premises, continued drinking cans of beer.

The first aircraft to become available to the party was the Piper Aztec. Soon after 4pm the luggage belonging to the first contingent of passengers was loaded into the Aztec, the passengers themselves were ushered aboard, and by 4.30pm the aircraft departed.

Although the pilots had expected the Chieftain and the Navajo to be ready by 4pm also, it was over an hour later before they finally became available for refuelling and loading. Meanwhile the passengers’ exuberant behaviour continued. In particular, the two drinking inside the flying school building were now visibly “the worse for wear”, prompting the pilot who was to fly the Navajo to declare he would not take them on his aircraft. Undaunted, they elected to travel on the Chieftain.

It was close to sunset by the time both IFR aircraft were finally ready for loading, and the operator’s Chief Pilot, who had given the young instructor his endorsement on the Chieftain the previous day, now came out to the aircraft to help, offering advice as to which seats should be allocated to the heavier passengers. There was argument amongst the passengers during the loading, some of it in loud voices, as to who would travel in which aircraft, and some shuffling of passengers and luggage between the two machines took place. Some of the passengers, clutching cans of beer, were clearly affected by alcohol.

But at last all was ready and before stepping out of the Chieftain, the Chief Pilot gave the nine passengers on board a preflight briefing on the advisability of keeping their seatbelts fastened in flight, and on the operation of the door and the emergency exit. He then closed the cabin door from the outside, the pilot started the engines, and the Chieftain taxied away for takeoff a few minutes before last light. The Navajo followed 10 minutes later.

Setting course from Moorabbin at 6.17pm, the Chieftain pilot selected the autopilot and climbed on track to the cruising altitude of 9000ft he had nominated in the flight plan. The planned track was Moorabbin/Wonthaggi-Bass/Launceston, cruising at 160kt (296km/h) for an elapsed time of 90 minutes. The aircraft’s endurance was 155 minutes.

In the meantime, after encountering more cloud than expected over Bass Strait, the pilot of the Piper Aztec had called Melbourne to request an updated report on conditions at Launceston. When this indicated the northerly wind off Bass Strait was likely to bring rain showers, with two octas of stratus cloud at 1000ft, and that there were heavy showers to the north and east, he wisely decided against continuing to Launceston that evening and reported they would divert to Flinders Island to remain there overnight.

At 6.32pm, when the Chieftain had not reported passing Wonthaggi, Melbourne Control called it, but could get no reply. However, the aircraft’s radar plot showed the flight to be continuing normally. A few minutes later, the radar controller saw the Chieftain was deviating to the left of its track, and again attempted to contact the pilot. Still he was unsuccessful and by 6.48pm the aircraft had drifted almost 10nm (19km) to the east of track. But at 6.58pm, by which time the heading had been corrected and the aircraft was converging again towards its planned track, the pilot called Melbourne Flight Service to report he had had a radio problem.

Ten minutes later the Chieftain, still cruising at just over 9000ft, passed beyond the coverage of Melbourne ATC’s enroute radar, but communications continued normally and at 7.27pm Melbourne Control instructed the aircraft, now 35nm (65km) northwest of Launceston, to call Launceston Tower.

Calling the Tower and reporting at 7000ft on descent, the Chieftain was cleared for a DME arrival, inbound on the 325 radial of the Launceston VOR. The DME approach procedure provides descent guidance in a series of steps at particular DME distances, using a specified radio navigation aid for directional guidance, to the visual circling area of the destination aerodrome. The DME procedure for Launceston showed that at 6 DME the aircraft could descend to 2000ft and at 3 DME to 1450ft, 888ft above the airport. If visual reference was not established by the time the aircraft reached the VOR, it was required to make a missed approach, climbing on a heading of 134°M to 3000ft.

The Launceston ATIS was broadcasting that Runway 32 was in use, the wind was from 320° at 5 to 10kt (9 to 19km/h), the QNH was 1012, the temperature 10°C, and there were two octas of cloud at 800ft. These conditions meant that the Chieftain, flying in from the northwest, would have to make a circling approach after becoming visual to land in the reciprocal direction on Runway 32.

At 7.30pm Launceston Tower called the Chieftain to advise that the two octas of cloud were clear of the inbound track, but that lower cloud was forming just north of the field and there was a chance the aircraft might not be visual by the time it reached the VOR, in which case the pilot would need to carry out an ILS approach via the Nile Locator, 7.5nm (14km) southeast of the runway threshold. The controller then telephoned the airport meteorological observer to ask what the scheduled 7.30pm searchlight check of cloud height had revealed, and was told it showed some seven octas of cloud at 800ft.

At 7.36pm the Tower called the Chieftain again, requesting its position and altitude. When the pilot reported 12 DME at 3300ft, the controller told him conditions were deteriorating, but it was possible he would get a break in the cloud. Reminding the pilot that if he was not visual on reaching the VOR he would have to make a missed approach, the controller again asked for the aircraft’s position and height. This time the pilot reported the aircraft was down to 1450ft at 2-3 DME and that they were still in cloud. The Tower then made a broadcast to three other aircraft inbound to Launceston, one of which was the Navajo, advising that conditions were deteriorating, and to expect an ILS approach.

Shortly afterwards at 7.41pm, the Chieftain pilot reported overhead the field but that he did not have its lights in sight and was going around. But when asked to confirm he was now on climb to 3000ft, the pilot instead replied he now had the field in sight, reporting a few seconds later that he was over the final approach path to Runway 32. The controller therefore cleared the aircraft for a visual approach to Runway 32 or for a missed approach to Nile, adding that it was cleared “to manoeuvre as preferred for Runway 32.” The pilot’s acknowledgement was to prove the Chieftain’s last transmission.

Witnesses on the ground watched the lights of the Chieftain as it tracked to the southeast of the field at a height of between 500 and 800ft. Flying at high speed, it then turned steeply left through 180° to enter an upwind leg, parallel with the main runway on its northeastern side, passing through patches of cloud. Towards the northwestern end of the runway it turned left again on to a close downwind leg for Runway 32, during which it appeared to be descending. Continuing to about a kilometre south of the runway threshold, now at a height of between 300 and 500ft, but with the engines apparently still at high power, the aircraft began another left turn on to base leg, encountering another patch of low cloud as it did so.

But when the witnesses again caught sight of the Chieftain late on base leg at a height of only about 200ft, they saw that it was in an excessively steep bank, at an angle of about 60°. The aircraft then suddenly lost height, striking a powerline crossing the approach path. Instantly the entire airport lighting was blacked out. A moment later the aircraft flew into the ground and burst into flames.

The airport fireman on duty in the fire station, seeing the electrical flash as the aircraft struck the wires, immediately despatched three fire tenders. The first reached the blazing aircraft in less than six minutes and, using foam, quickly extinguished the fire. The firecrew found that three passengers and the pilot had extricated themselves from the burning aircraft, but six passengers had died in the fire. An ambulance reached the crash site 19 minutes after the accident and took the survivors to hospital.

Bureau of Air Safety Investigation

Launceston Airport, 8nm (15km) southeast of the city in flat farming country near the township of Evandale, has a mean elevation of 557ft. Its one sealed runway, aligned 14-32, is 1981m in length and is equipped with an ILS and Category 1 precision approach lighting for Runway 32. Two NDB masts, each with an elevation of 609ft, are situated just over a kilometre southeast of the Runway 32 threshold. The Launceston-Evandale road, with a high tension powerline parallelling it, crosses the approach path at an oblique angle immediately on the northern side of the NDB masts, with the NDB transmitter building adjoining the road.

The accident site was in a paddock also adjoining the road, but on its opposite side, the aircraft having severed the powerline bordering both the road and the paddock after narrowly missing the NDB installation while on a heading of 330°M (see photograph). The aircraft had then struck the ground 13m further on, bounced back into the air for 20m, and finally skidded to a stop 150m beyond the powerline.

Bureau of Air Safety investigators found that the Chieftain, descending at an angle of about 20° while banked some 28° to the left, had struck the powerline with its starboard propeller. Simultaneously the lowered port wing had cut into a line of scrub growing along the roadside beneath the powerline. Calculations indicated the aircraft’s groundspeed at the time was about 107kt (198km/h).

The wreckage was lying upright on the underside of its fuselage, but fire had destroyed most of the structure forward of the cabin door. The starboard propeller had been torn from its engine and all three of its blades showed evidence of having struck high tension cables. Both propellers had been in fine pitch at the time of impact. The undercarriage had been selected down and was in the process of extending when the aircraft struck the ground. The flaps were still in their retracted position.

Prior to departure the pilot had completed a load sheet providing for full fuel plus nine passengers and their luggage. This showed the aircraft’s takeoff weight was right on its maximum of 3178kg and that the CofG, though towards the aft limit, was within specified limits. In actual fact, both the fuel and passenger weights were underestimated, with the result that at takeoff the aircraft was about 95kg in excess of its maximum permissible weight. But because of the fuel consumed during the flight, the weight was less than the maximum at the time of the accident.

Detailed examination of the wreckage found no defects of any kind that were likely to have contributed to the accident. The fire was evidently started when sparks from the battery ignited fuel spilling from ruptured lines during the impact sequence.

Postmortem examination of the victims, all but one of whom were seated on the right hand side of the aisle, showed that none had received fatal injuries in the impact. All had died in the fire, five of them with their seatbelts still fastened. It seemed possible that during the impact, those in the right hand seats were thrown heavily against the right side of the cabin, briefly stunning them. The fatally burnt passenger seated on the left immediately behind the cockpit, had received chest injuries that might have disabled him. All six victims had high blood alcohol levels, ranging from 0.041 to 0.218, with four of them well in excess of 0.1. The alcohol levels of at least some were such as to have had a detrimental effect on their ability to escape from the wreckage before the fire overwhelmed them.

The four survivors all left the burning aircraft without help. The mid-cabin emergency exit had sprung open in the impact and the passenger seated on the left opposite it, together with the pilot, climbed through the opening. The two passengers seated on the left immediately ahead of and behind the main cabin door, left through this door.

None of the survivors could recall the final moments of the flight, but the pilot’s first words when interviewed in hospital were that it had been “a pig of a trip”. He explained that the passengers were noisy during the flight, and that he was constantly interrupted by their questions. Even when making the circling approach to land at Launceston, the passenger in the second pilot’s seat had continued to interrupt him, prompting the pilot to tell him he was “unhappy” with his conduct.

The pilot was 23 years of age and had logged a total of 700 hours. Of this, according to his logbook, 63 hours were night flying, 36 hours were instrument flying, and 46 hours were in twin engined aircraft.

His initial twin engined training was in a Piper PA-44 Seminole and 18 months before the accident he was endorsed on the PA-23, flying a total of 3.2 hours on this type. Four months before the accident he completed his command instrument rating, again in a Seminole, most of the training being flown at night. An endorsement on Partenavia P.68 aircraft followed several weeks later, after which he flew a Partenavia to Launceston, carrying out a DME arrival at night, followed by a circling approach to land on Runway 32. His total experience on the Partenavia was 5.3 hours.

Since that time the pilot had logged 2.7 hours of instrument flying in single engined aircraft, his last ILS approach having been flown in early June, more than three months before the accident. His logbook did not record any instrument approaches during the 90 days preceding the accident.

It was obvious the actual weather at Launceston was a good deal worse than indicated by the forecast the pilot obtained earlier in the day, but it was not until he was on descent that he learned of this deterioration. He was thus forced to contemplate an ILS approach, something for which his lack of recent experience had left him ill-prepared. So when he suddenly broke clear of cloud and sighted the lights of the airport, the opportunity to make a visual approach instead would doubtless have seemed a reprieve.

The poor visibility, particularly the low ceiling, obviously prompted the pilot to descend to a low level and fly the circuit close in to the runway. This undoubtedly created a high workload and probably affected the pilot’s judgement of the turn on to base leg, resulting in the need to use excessively steep angles of bank.

A low altitude circling approach at night in marginal visibility is extremely demanding, requiring a high degree of flying skill and concentration. The circuit has to be flown by reference to runway lights and other markings identifying the approach end of the runway, as well as by reference to flight instruments at the same time. At such low heights there is little time to correct altitude errors, and close attention must be paid to the altimeter. Airspeed has also to be monitored, while pre-landing checks and lowering the undercarriage and flaps all add to the workload. For an experienced pilot current on the aircraft type, such a high workload may not pose a problem. But for an inexperienced pilot trying to cope with a complex aircraft with which he is still unfamiliar, the workload could become overwhelming.

In this case the pilot was flying an aircraft of substantially higher weight and performance than he was accustomed to, and with which he had very little familiarity. His endorsement training only the previous day had included no night or instrument flying, no low level circuits, and no handling of the aircraft at maximum weight or aft CofG. Furthermore, his decision to use the autopilot throughout most of the flight from Moorabbin denied him even this opportunity to become accustomed to the feel of the heavily loaded Chieftain. Thus when he finally had to revert to hand flying, this in itself would have demanded a high level of concentration, let alone the special demands of the low level night circling approach.

The picture that emerged from the investigation was that of a pilot, inexperienced in multi-engined aircraft, attempting to fly an unfamiliar low level night circling approach in marginal visibility in a high performance aircraft in which he also had very limited experience. This almost certainly resulted in him being a “long way behind” his aircraft, setting the scene for the errors of judgement that led to the accident. The repeated distractions from the boisterous, alcohol affected passengers would have only added to the pilot’s near insurmountable difficulties. It was significant that when the pilot reported over the approach end of Runway 32 while turning steeply on to the upwind leg, the stall warning could be heard in the background.

One of the questions faced by the investigators was why the Chief Pilot, generally familiar as he was with the young pilot’s limited twin engined and instrument experience, and having seen for himself the condition of some of the passengers, authorised the flight to depart. It was possible however that the earlier forecast of good weather, indicating that conditions would allow a visual flight to Launceston, could have been a factor in the Chief Pilot’s decision.

The Chief Pilot was unaware until after the accident that Civil Aviation Regulations limit cost sharing of private flights to a maximum of six people in any one aircraft.

Civil Aviation Regulations

Footnote: BASI makes the point that its investigation reports are provided to promote aviation safety. In no case are they intended to imply blame or liability.