Accident Fairchild SA227-DC Metro 23 VH-TFU, Saturday 7 May 2005
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Date:Saturday 7 May 2005
Time:11:43
Type:Silhouette image of generic SW4 model; specific model in this crash may look slightly different    
Fairchild SA227-DC Metro 23
Owner/operator:Aero-Tropics Air Services
Registration: VH-TFU
MSN: DC-818B
Year of manufacture:1992
Total airframe hrs:26877 hours
Cycles:28529 flights
Engine model:Garrett TPE331-12UHR-701G
Fatalities:Fatalities: 15 / Occupants: 15
Other fatalities:0
Aircraft damage: Destroyed, written off
Category:Accident
Location:12 km NW of Lockhart River Airport, QLD (IRG) -   Australia
Phase: Approach
Nature:Passenger - Scheduled
Departure airport:Bamaga Airport, QLD (ABM/YBAM)
Destination airport:Lockhart River Airport, QLD (IRG/YLHR)
Investigating agency: ATSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
The pilot in command and copilot commenced duty in Cairns for the scheduled Cairns (CNS) - Lockhart River (IRG) - Bamaga (ABM) - Lockhart River (IRG) - Cairns (CNS) flight. The flight was operated by Transair but conducted on behalf of Aero-Tropics Air Services. Aero-Tropics would provide ground handling, pilot briefing facilities and marketing services. Transair provided the airplane and crew.
The Metro 23 aircraft departed Cairns at 08:31. During the descent to Lockhart River on the northbound flight, the crew intended to perform a runway 30 RNAV (GNSS) approach. Late in the approach, the crew appropriately manoeuvred the aircraft to land on runway 12. The engines were shutdown at 09:50. The aircraft departed Lockhart River at 09:58 and arrived at Bamaga at 10:39. The aircraft was refuelled at Bamaga for the return flight to Cairns via Lockhart River to collect two passengers. The pilot in command commented to the ground agent prior to departing Bamaga that the weather was 'bad' at Lockhart River and it may not be possible to land there. The forecast conditions at the aerodrome included a broken10 cloud base 1,000 ft above the aerodrome for periods of up to 60 minutes. The aircraft departed Bamaga at 11:07 and climbed to the cruising altitude of FL170. Descent was commenced at 11:32. Three minutes later the copilot advised Brisbane ATC that the aircraft was on descent, passing 10,000 ft AMSL with an estimated time of arrival at Lockhart River of 11:38. At 11:39 the copilot broadcast on the CTAF (Common Traffic Advisory Frequency) that the crew was conducting the runway 12 RNAV (GNSS) approach, and that the aircraft was at the 'Whisky Golf' (LHRWG) waypoint and tracking for the 'Whisky India' (LHRWI) waypoint. At 11:41 the airplane was over the LHRWI intermediate fix and descent was recommenced at 4.8 NM from the LHRWF waypoint. This was 3.1 NM before the descent point specified on the approach chart for the 3.49 degree constant angle approach path to the missed approach point. After levelling briefly at 3000 feet 18 degrees of flaps were selected. The aircraft then commenced descent 1.4 NM before the final approach fix (FAF). This was 0.3 NM (approximately 7 seconds) after the descent point specified for the constant angle approach path. The average rate of descent was 1000 ft/min, increasing to 1700 ft/min. At 11:43 the Metro was over the FAF at an altitude of 2379 feet. The altitude at this stage should have been 2860 feet. The flight descended then through the segment minimum safe altitude of 2,060 ft. It continued to descend until it flew into the side of a heavily timbered ridge in the Iron Range National Park. The height of the initial impact with trees was 1,210 ft, which was about 90 ft below the crest of the ridge.

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.

CONTRIBUTING FACTORS RELATING TO TRANSAIR PROCESSES
- Transair's flight crew training program had significant limitations, such as superficial or incomplete ground-based instruction during endorsement training, no formal training for new pilots in the operational use of GPS, no structured training on minimising the risk of controlled flight into terrain, and no structured training in crew resource management and operating effectively in a multi-crew environment. (Safety Issue)
- Transair's processes for supervising the standard of flight operations at the Cairns base had significant limitations, such as not using an independent approved check pilot to review operations, reliance on passive measures to detect problems, and no defined processes for selecting and monitoring the performance of the base manager. (Safety Issue)
- Transair's standard operating procedures for conducting instrument approaches had significant limitations, such as not providing clear guidance on approach speeds, not providing guidance for when to select aircraft configuration changes during an approach, no clear criteria for a stabilised approach, and no standardised phraseology for challenging safety-critical decisions and actions by other crew members. (Safety Issue)
- Transair had not installed a terrain awareness and warning system, such as an enhanced ground proximity warning system, in VH-TFU.
- Transair's organisational structure, and the limited responsibilities given to non-management personnel, resulted in high work demands on the chief pilot. It also resulted in a lack of independent evaluation of training and checking, and created disincentives and restricted opportunities within Transair to report safety concerns with management decision making. (Safety Issue)
- Transair did not have a structured process for proactively managing safetyrelated risks associated with its flight operations. (Safety Issue)
- Transair's chief pilot did not demonstrate a high level of commitment to safety. (Safety Issue)

CONTRIBUTING FACTORS RELATING TO THE CIVIL AVIATION SAFETY AUTHORITY'S PROCESSES
- CASA did not provide suffici

Accident investigation:
cover
  
Investigating agency: ATSB
Report number: ATSB Occurrence 200501977
Status: Investigation completed
Duration: 1 year and 11 months
Download report: Final report

Sources:

SKYbrary 
ABC
ATSB Occurrence Number 200501977

Statistics

  • 22nd worst accident in 2005
  • 2nd worst accident of this aircraft type
  • 2nd worst accident of this aircraft type at the time

Location

Revision history:

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