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SW4, vicinity Lockhart River Queensland Australia, 2005

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Summary
On 7 May 2005, a Fairchild Aircraft Inc. SA227-DC Metro 23 aircraft, was being operated by Transair on an IFR flight from Bamaga to Cairns, with an intermediate stop at Lockhart River, Queensland. The aircraft impacted terrain approximately 11 km north-west of the Lockhart River aerodrome and was destroyed by the impact forces and an intense, fuel-fed, post-impact fire.
Event Details
When May 2005
Actual or Potential
Event Type
Controlled Flight Into Terrain (CFIT), Human Factors
Day/Night Day
Flight Conditions IMC
Flight Details
Aircraft SWEARINGEN Metroliner
Operator Transair
Domicile Australia
Type of Flight Public Transport (Passenger)
Origin Bamaga/Northern Peninsula Airport
Intended Destination Lockhart River Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Descent
ENR / APR
Location - Airport
Airport vicinity Lockhart River Airport
CFIT
Tag(s) Into terrain,
No Visual Reference,
Vertical navigation error,
IFR flight plan
HF
Tag(s) Distraction,
Inappropriate crew response - skills deficiency,
Ineffective Monitoring,
Procedural non compliance
Safety Net Mitigations
GPWS Available but ineffective
Outcome
Damage or injury Yes
Aircraft damage Hull loss
Fatalities Most or all occupants (15)
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation
Investigation Type
Type Independent

Description

On 7 May 2005, a Fairchild Aircraft Inc. SA227-DC Metro 23 aircraft, was being operated by Transair on an Instrument Flight Rules (IFR) flight from Bamaga to Cairns, with an intermediate stop at Lockhart River, Queensland. The aircraft impacted terrain approximately 11 km north-west of the Lockhart River aerodrome. At the time of the accident, the crew was conducting an area navigation global navigation satellite system RNAV (GNSS) non-precision approach to runway 12. The aircraft was destroyed by the impact forces and an intense, fuel-fed, post-impact fire. There were no survivors.

The Investigation

The Investigation into the Accident was carried out by Australian Transport Safety Bureau (ATSB), who specified the following “Contributing factors relating to occurrence events and individual actions”:

  • "The crew commenced the Lockhart River Runway 12 RNAV (GNSS) approach, even though the crew were aware that the copilot did not have the appropriate endorsement and had limited experience to conduct this type of instrument approach.
  • The descent speeds, approach speeds and rate of descent were greater than those specified for the aircraft in the Transair Operations Manual. The speeds and rate of descent also exceeded those appropriate for establishing a stabilised approach.
  • During the approach, the aircraft descended below the segment minimum safe altitude for the aircraft’s position on the approach.
  • The aircraft’s high rate of descent, and the descent below the segment minimum safe altitude, were not detected and/or corrected by the crew before the aircraft collided with terrain.
  • The accident was almost certainly the result of controlled flight into terrain."

Contributing factors relating to local conditions:

  • "The crew probably experienced a very high workload during the approach.
  • The crew probably lost situational awareness about the aircraft’s position along the approach.
  • The pilot in command had a previous history of conducting RNAV (GNSS) approaches with crew without appropriate endorsements, and operating the aircraft at speeds higher than those specified in the Transair Operations Manual.
  • The Lockhart River Runway 12 RNAV (GNSS) approach probably created higher pilot workload and reduced position situational awareness for the crew compared with most other instrument approaches. This was due to the lack of distance referencing to the missed approach point throughout the approach, and the longer than optimum final approach segment with three altitude limiting steps.
  • The copilot had no formal training and limited experience to act effectively as a crew member during a Lockhart River Runway 12 RNAV (GNSS) approach."

For the complete list of Findings, see Section 3 of the Final Report (Further Reading)

Safety Actions

The investigation report identifies a range of contributing and other safety factors relating to the crew of the aircraft, Transair's processes, regulatory oversight of Transair by the Civil Aviation Safety Authority, and RNAV (GNSS) approach design and chart presentation. It also details safety action taken by various agencies to address the identified safety issues, and includes safety recommendations relating to those safety issues that had not been addressed by relevant agencies at the time of publication of the report.

For the complete breakdown of the Safety Actions in regard to the identified safety issues, see Section 4 of the Final Report (Further Reading)

Related Articles

Further Reading

The complete ATSB Accident Report (Aviation Occurrence Report 200501977) which comprises of main body and appendices.