The de Havilland Canada DHC-2 Beaver floatplane that fatally crashed on New Year’s Eve was not on the operator’s standard flightpath before it impacted Jerusalem Bay just outside Sydney, the Australian Transport Safety Bureau (ATSB) says.
The findings are in the transport safety investigator’s preliminary report into the accident, which resulted in the death of the pilot and five passengers on board.
DHC-2 Beaver VH-NOO, operated by Sydney Seaplanes, took off from Cottage Point on a charter flight bound for Rose Bay at about 1500 on December 31 2017.
The ATSB report noted the standard flightpath was for the aircraft to climb to the north after taking off from Cottage Point, turn right towards the Hawkesbury River and then, once gaining sufficient altitude to clear terrain, continue onwards to Rose Bay.
However, witnesses said they saw the aircraft fly towards Jerusalem Bay to the north of the standard flightpath “at an altitude below the height of the surrounding terrain”.
“Shortly after entering Jerusalem Bay, numerous witnesses reported seeing the aircraft suddenly enter a steep right turn and the aircraft’s nose suddenly drop before the aircraft collided with the water in a near vertical position,” the ATSB report said.
The ATSB said the initial examination of the aircraft wreckage recovered by the New South Wales Police Force Diving Unit found no evidence of a birdstrike or collision with an object prior to take-off or in-flight.
Further, there was no evidence of an in-flight break-up or pre-impact structural damage. And tests on fuel samples from the aircraft found no presence of water or any any particle matter.
Nor was there any indication of flight control issues.
“Damage to the wings was consistent with the aircraft being banked to the right at the time of impact,” the ATSB said.
The flaps were in the “climb” position of 15 ± 1 degrees.
Sydney Seaplanes CEO Aaron Shaw as saying the Beaver pilot’s actions were “inexplicable”.
“The key question arising from the report is why the plane crashed, approximately halfway down Jerusalem Bay, which is surrounded by steep terrain and has no exit,” Shaw said in a statement to media on Wednesday.
“It is not a route we authorise in our Landing and Take-off Register and the plane simply should not have been where it was.”
The aircraft is then reported to have entered into an 80 to 90-degree bank angle turn.
“A turn of this nature at low altitude by a pilot with Gareth’s skills, experience and intimate knowledge of the location is totally inexplicable.”
The Beaver was not equipped with a cockpit voice or flight data recorder – there is no regulatory requirement for this size of aircraft to have either – the ATSB report notes.
The investigator says it has retained VH-NOO’s “engine, propeller and a number of aircraft components” for “further examination”.
The Beaver’s Pratt & Whitney R985 nine-cylinder radial piston engine had been fitted to the aircraft during a scheduled maintenance check performed in November 2017, at which point it had 95 hours time-in-service following a maintenance inspection in the USA.
VH-NOO was manufactured in 1963 and first registered in Australia in 1964.
This was the second fatal accident involving VH-NOO, the first occurred in November 1996 when the aircraft was configured for aerial agriculture operations with fixed undercarriage (rather than floats).
“The aircraft was subsequently repaired, issued with a Certificate of Airworthiness and re-entered service, registered as VH-NOO, in 2000,” the ATSB preliminary report said.
“Sydney Seaplanes acquired the aircraft in 2006.”
Sydney Seaplanes suspended all operations following the accident until January 15, when it resumed operations with its Cessna Caravan amphibious aircraft.
Following the accident, the company also carried out a review of the maintenance status of all its aircraft, with “all maintenance actions found to have been carried out as required”, the ATSB said.
All Sydney Seaplanes pilots and operations staff had completed threat and error management training, while pilots had also completed ground training on low-level flying and wind shear.
“Prior to commencing charter flights, all pilots will be re-checked in accordance with the operator’s proficiency standards. This will include additional low-level and stall training,” the ATSB said.
The pilot of the aircraft had more than 10,000 flying hours’ experience, of which about 9,000 hours were on floatplanes, the ATSB said.
Weather information from two Bureau of Meteorology (BOM) automatic weather stations (AWS) – at Terrey Hills and Gosford – and witness reports indicated the wind was blowing directly into Jerusalem Bay at the time of the accident, “which would have resulted in the aircraft experiencing a tailwind at the time it entered Jerusalem Bay”.
The investigation is continuing. The ATSB said the Transportation Safety Board (TSB) of Canada and the United States National Transportation Safety Board (NTSB) were also involved in the investigation, while a representative from the the United Kingdom (UK) Air Accident Investigation Branch (AAIB) has been appointed as an expert to the investigation team.
The five passengers killed were from the UK.
The ATSB says its ongoing investigation will focus on a number of areas including:
- engine, propeller and aircraft component examinations;
- flight and engine control positions;
- aircraft maintenance history;
- obtaining and evaluating witness information;
- pilot qualifications, experience and medical information;
- impact sequence;
- aircraft performance and handling characteristics;
- aircraft weight and balance;
- operator policies and procedures;
- stall warning systems;
- nature of seaplane operations;
- environmental influences;
- sources of recorded information;
- similar occurrences in Australia and internationally.
The preliminary report can be read in full on the ATSB website.