Accident Cessna 404 Titan VH-OZO, Wednesday 11 March 2020
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Date:Wednesday 11 March 2020
Time:09:19
Type:Silhouette image of generic C404 model; specific model in this crash may look slightly different    
Cessna 404 Titan
Owner/operator:Air Connect Australia
Registration: VH-OZO
MSN: 404-0653
Year of manufacture:1980
Total airframe hrs:28193 hours
Engine model:Teledyne-continental TSIO-520-M
Fatalities:Fatalities: 5 / Occupants: 5
Other fatalities:0
Aircraft damage: Destroyed
Category:Accident
Location:6,4 km SE of Lockhart River Airport, QLD (IRG/YLHR) -   Australia
Phase: Approach
Nature:Passenger - Non-Scheduled/charter/Air Taxi
Departure airport:Cairns Airport, QLD (CNS/YBCS)
Destination airport:Lockhart River Airport, QLD (IRG/YLHR)
Investigating agency: ATSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
The Cessna 404 aircraft, registered VH-OZO, was being operated by Air Connect Australia to conduct a passenger charter flight from Cairns to Lockhart River, Queensland, Australia. On board were the pilot and 4 passengers, and the flight was being conducted under the instrument flight rules (IFR).

Consistent with the forecast, there were areas of cloud and rain that significantly reduced visibility at Lockhart River Airport. On descent, the pilot obtained the latest weather information from the airport’s automated weather information system (AWIS) and soon after commenced an area navigation (RNAV) global satellite system (GNSS) instrument approach to runway 30.

The pilot conducted the first approach consistent with the recommended (3°) constant descent profile, and the aircraft kept descending through the minimum descent altitude (MDA) of 730 ft and passed the missed approach point (MAPt). At about 400 ft, the pilot commenced a missed approach.

After conducting the missed approach, the pilot immediately commenced a second RNAV GNSS approach to runway 30. 

During this approach, the pilot commenced descent from 3,500 ft about 2.7 NM prior to the intermediate fix (or 12.7 NM prior to the MAPt). The descent was flown at about a normal 3° flight path, although about 1,000 ft below the recommended descent profile. While continuing on this descent profile, the aircraft descended below the MDA. It then kept descending until it collided with terrain 6.4 km (3.5 NM) short of the runway. The pilot and 4 passengers were fatally injured, and the aircraft was destroyed.

Contributing factors

- While the pilot was operating in the vicinity of Lockhart River Airport, there were areas of cloud and rain that significantly reduced visibility and increased the risk of controlled flight into terrain. In particular, the aircraft probably entered areas of significantly reduced visibility during the second approach.
- After an area navigation (RNAV) global satellite system (GNSS) approach to runway 30 and missed approach, the pilot immediately conducted another approach to the same runway that was on a similar gradient to the recommended descent profile but displaced about 1,000 ft below that profile. While continuing on this descent profile, the aircraft descended below a segment minimum safe altitude and the minimum descent altitude, then kept descending until the collision with terrain about 6 km before the runway threshold.
- Although the exact reasons for the aircraft being significantly below the recommended descent profile and the continued descent below the minimum descent altitude could not be determined, it was evident that the pilot did not effectively monitor the aircraft’s altitude and descent rate for an extended period.
- When passing the final approach fix (FAF), the aircraft’s lateral position was at about full-scale deflection on the course deviation indicator (CDI), and it then exceeded full-scale deflection for an extended period. In accordance with the operator’s stabilised approach procedures, a missed approach should have been conducted if the aircraft exceeded half full-scale deflection at the FAF, however a missed approach was not conducted.
- The pilot was probably experiencing a very high workload during periods of the second approach. In addition to the normal high workload associated with a single pilot hand flying an approach in instrument meteorological conditions, the pilot’s workload was elevated due to conducting an immediate entry into the second approach, conducting the approach in a different manner to their normal method, the need to correct lateral tracking deviations throughout the approach, and higher than appropriate speeds in the final approach segment.
- The aircraft was not fitted with a terrain avoidance and warning system (TAWS). Such a system would have provided visual and aural alerts to the pilot of the approaching terrain for an extended period, reducing the risk of controlled flight into terrain.
- Although the aircraft was fitted with a GPS/navigational system suitable for an area navigation (RNAV) global satellite system (GNSS) approach and other non-precision approaches, it was not fitted with a system that provided vertical guidance information, which would have explicitly indicated that the aircraft was well below the recommended descent profile.
- Although the operator had specified a flight profile for a straight-in approaches and stabilised approach criteria in its operations manual, and encouraged the use of stabilised approaches, there were limitations with the design of these procedures. In addition, there were limitations with other risk controls for minimising the risk of controlled flight into terrain (CFIT), including no procedures or guidance for the use of the terrain awareness function on the aircraft’s GNS 430W GPS/navigational units and limited monitoring of the conduct of line operations. (Safety Issue)

Accident investigation:
cover
  
Investigating agency: ATSB
Report number: AO-2020-017
Status: Investigation completed
Duration: 2 years and 9 months
Download report: Final report

Sources:

https://www.theaustralian.com.au/nation/lockhart-river-plane-crash-five-feared-dead-in-cape-york-flight-disaster/news-story/9e0d5b22c009b8e694bcd07d45d120ce
https://www.9news.com.au/national/queensland-plane-crash-lockhart-river-far-north/a7d03e3e-67de-472f-901d-b267333caca1
https://www.abc.net.au/news/2020-03-11/lockhart-river-search-plane-crash-beach-qld/12046400

Data _______________________________

https://flightaware.com/live/flight/VHOZO
https://www.flickr.com/photos/143294701@N04/33977403212/ (Photo)

ATSB _______________________________
https://www.atsb.gov.au/publications/investigation_reports/2020/aair/ao-2020-017/

Location

Images:


Photo: ATSB

Media:

Revision history:

Date/timeContributorUpdates
11-Mar-2020 05:18 Captain Adam Added
11-Mar-2020 06:53 harro Updated [Departure airport, Destination airport]
11-Mar-2020 06:55 B777 Updated [Total fatalities, Phase, Departure airport, Destination airport, Source, Narrative]
11-Mar-2020 06:56 harro Updated [Location, Nature]
11-Mar-2020 07:39 RobertMB Updated [Operator, Source]
11-Mar-2020 18:05 RobertMB Updated [Time, Operator, Source, Narrative]
11-Mar-2020 20:16 Iceman 29 Updated [Source, Embed code, Photo]
12-Mar-2020 13:55 Captain Adam Updated [Operator, Location, Source, Embed code, Narrative]
12-Mar-2020 16:20 Iceman 29 Updated [Source, Embed code]
12-Mar-2020 16:21 Iceman 29 Updated [Embed code]
26-Mar-2020 08:02 Anon. Updated [Embed code, Narrative]
10-Mar-2021 20:25 harro Updated [Photo]
08-May-2021 16:59 harro Updated [Operator, Source]
08-May-2021 17:00 harro Updated
04-May-2022 09:44 Anon. Updated [Narrative]
02-Nov-2023 18:20 harro Updated
22-Nov-2023 20:06 harro Updated [Other fatalities, Accident report]

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