Air crash investigations: How seven people lost their lives

WEATHER conditions are considered factors in two recent fatal aircraft crashes, the loss of the Huey helicopter that killed five people off Anna Bay, and the light aircraft tragedy that claimed the lives of a father and son near Dorrigo.

The Australian Transport Safety Bureau has released preliminary investigations into the two crashes where both pilots were operating under visual flight rules. 

Jocelyn Villanueva and her partner Gregory Miller, Grant Kuhnemann, pilot David Kerr, Jamie Ogden.
Jocelyn Villanueva and her partner Gregory Miller, Grant Kuhnemann, pilot David Kerr, Jamie Ogden.

The ATSB revealed that in both incidents neither pilot had qualifications to operate in instrument meteorological conditions or at night.  

It released its reports urging other pilots to take appropriate actions to avoid a weather or low-visibility related accident.

In the Bell UH-1H 'Huey' VH-UVC incident five people were killed after the helicopter impacted the ocean after last light at a time of reported severe weather near Anna Bay on September 6.

Jamie Ogden and Grant Kuhnemann, both from Queensland, Jocelyn Villanueva and Gregory Miller, a married couple from Sydney, and the helicopter's pilot and owner David Kerr from Queensland all perished in the crash.

This photo of Matthew and Jeffrey was  taken a week before their fatal crash.
This photo of Matthew and Jeffrey was taken a week before their fatal crash. Facebook

Then on September 20, a Queensland father and son Jeff and Matthew Hills died when the four-seater VH-DJU collided with heavily-wooded terrain in the Dorrigo National Park near Coffs Harbour, in forecast weather conditions of low broken cloud.

With the release of the preliminary reports into both crashes, the ATSB said investigations will continue to look at the weather and environmental conditions at the time of the accidents, among a number of other factors.

"It is important to stress that both investigations are still in their early stages, and the ATSB will not publish its findings until the final investigation reports are released," ATSB Executive Director Transport Safety Nat Nagy said.

"But the ATSB notes that weather and environmental conditions are a focus for both investigations, and weather-related general aviation accidents remain one of the ATSB's most significant causes for concern in aviation safety.

"Pilots without a current instrument rating should always be prepared to amend and delay plans to fly due to poor or deteriorating weather conditions, and not to push on.

"Weather and low visibility-related accidents often have fatal outcomes, which is all the more tragic because they are almost always avoidable."

A total of 101 occurrences of VFR pilots inadvertently flying into instrument meteorological conditions in Australian airspace were reported to the ATSB in the decade from July 1,  2009 to  June 30, 2019.

Of those occurrences, nine were accidents resulting in 21 deaths.

ATSB
ATSB

WHAT HAPPENED - THE DORRIGO PLANE CRASH

At about 0640 Eastern Standard Time on 20 September 2019, a Mooney M20J aircraft, registered VH-DJU, departed Murwillumbah for a private flight under the visual flight rules (VFR) to Taree.

On board were the pilot and one passenger.

After departing Murwillumbah, the aircraft climbed to 6,500 ft above mean sea level (AMSL) on a direct track to Taree.

At 0717, when the aircraft was positioned north of Grafton, the pilot contacted air traffic control (ATC) and requested a clearance to transit controlled airspace at an altitude of 6,500 ft.

The air traffic controller advised him that a clearance to enter controlled airspace was not available at 6,500 ft and provided the option to request clearance from the Coffs Harbour control tower at a lower altitude.

The pilot subsequently contacted the Coffs Harbour control tower and was advised by the controller that due to the extensive cloud cover, the only way to transit the airspace VFR would be at an altitude not above 1,000 ft.

The pilot acknowledged this information and advised that he would descend to that altitude.

However, at 0724, the pilot advised the tower controller that he was operating in clear conditions at 4,100 ft AMSL and would remain on that track and request a clearance upon reaching the airspace boundary.

The controller acknowledged the request and asked that the pilot report entering controlled airspace.

The aircraft did not subsequently enter controlled airspace and no further broadcasts were heard from the aircraft.

A review of recorded ATC information identified that after the pilot reported that he was operating in clear conditions, the aircraft was climbed to about 4,500 ft and continued on a direct track until about 0733.

At that time, the aircraft commenced descending at an average rate of about 850 ft per minute until the last recorded position at 0734. The aircraft was last recorded at an altitude of 3,564 ft and a ground speed of 165 kt 

ATSB
ATSB

In response to the aircraft not arriving at Taree as expected, a search was initiated, although it was initially hampered by poor weather in the vicinity of the aircraft's last known position.

The aircraft was subsequently found to have impacted terrain in line with the recorded track, at an elevation of 2,920 ft, about 2.8 km south of the last recorded position.

The two persons on board were fatally injured and the aircraft was destroyed.

Aircraft details

The Mooney M20J is a four‑seat, piston-engine aircraft with a two-blade variable-pitch propeller and retractable tricycle landing gear. VH-DJU (serial number 24-1075, Figure 2) was manufactured in 1981 and first registered with the Civil Aviation Safety Authority in 2005.

The pilot purchased the aircraft on 6 July 2019, about 3 months prior to the accident, and had flown about 31 hours in the aircraft. The most recent entry on the maintenance release was 11 days prior to the accident (9 September 2019) and showed that the aircraft had accumulated 3,295 hours' total time‑in‑service.

ATSB
ATSB

Wreckage and site information
The accident site was located on a heavily wooded mountain side, about 26 km west of Coffs Harbour Airport, within the Dorrigo National Park. The highest point in the surrounding area was 3,925 ft (Figure 3).

The wreckage trail was on an approximate north to south heading, in line with the last recorded flight path.

All aircraft components were accounted for at the site.

On-site examination of the wreckage, surrounding damage to vegetation and ground markings identified that the aircraft impacted trees in about level flight with the landing gear and flaps retracted.

The aircraft was severely damaged during the accident, however examination of the wreckage did not identify any pre-impact defects with the engine, flight controls or aircraft structure.

Both wing fuel tanks had ruptured and a quantity of fuel had leaked into the soil. There was no fire.

Some aircraft components, instruments and the aircraft log book were recovered from the accident site.

These items were taken to the ATSB's technical facility in Canberra for further examination.

Meteorological details

The Bureau of Meteorology weather station located at Coffs Harbour Airport, 26 km east of the accident site, recorded the following information (cloud levels AMSL) at 0730, 4 minutes prior to the accident:

Scattered cloud at 2,218 ft, broken cloud at 2,818 ft and broken cloud at 3,618 ft.
At that time, the recorded wind was from the north-west at a speed of 3 kt.
A witness located 10 km south-east of the accident site observed that at the time of the accident, the cloud base was at the base of the mountain range encompassing the accident site.

Further investigation
The investigation is continuing and will include examination of: meteorological conditions and pre‑flight preparation, pilot qualifications, experience and medical history, recovered aircraft components and instrumentation, aircraft maintenance documentation and operational records, the provision of air traffic services.

WHAT HAPPENED - THE ANNA BAY CRASH

On 6 September 2019, at 1430 Eastern Standard Time, the pilot of a UH-1H helicopter registered VH‑UVC (UVC) departed Archerfield Airport, Queensland, with four passengers on board.

The pilot was conducting a private flight for the purpose of repositioning the helicopter to Bankstown Airport, New South Wales.

At about 1600, the pilot landed at Coffs Harbour, New South Wales to refuel the helicopter.

Following refuelling, the pilot departed at about 1648 and tracked to the south.

At 1755, the pilot made contact with Williamtown Tower, requesting clearance to track south via the Visual Flight Rules lane.

The pilot also requested a climb to higher altitude, to take advantage of favourable winds.

The Williamtown Tower controller advised the pilot to contact Williamtown Approach (Approach) for clearance.

At 1757, the pilot of UVC made contact with Approach and requested clearance.

At 1758, the Approach controller identified UVC's position as 7.4 km (4 nautical miles) to the north-east of Broughton Island, and advised the pilot he could operate at whatever altitude was required provided it was not below 2,400 ft.

The pilot responded with a request to operate between 3,000 and 3,500 ft.

At 1758 UVC was cleared to track coastal southbound at a block altitude between 3,000 and 3,500 ft.

At 1759, following an inquiry from the Approach controller, the pilot advised that Bankstown was his intended destination.

At 1800, the pilot was advised that if any further track and altitude changes were required to advise accordingly. While no response was required, the pilot did not acknowledge the transmission.

At 1801, the controller again contacted UVC to offer alternative tracking if required.

The pilot responded requesting to remain on the eastern side of the romeo five seven eight alpha (R578A) restricted area.

The controller clarified this request and, in response, the pilot advised if it was not available he would continue on the VFR coastal route. The pilot was then cleared to track as required for Bankstown Airport.

The track clearance was acknowledged by the pilot at 1802.

At 1805, the Approach controller contacted the pilot to confirm that operations were normal, having observed that the altitude of UVC had dropped to 2,700 ft.

The pilot acknowledged the altitude drop, commenting on a sudden wind gust affecting the helicopter's altitude.

The controller responded by providing clearance for the pilot to operate between 2,400[3] and 3,500 ft.

This was acknowledged by the pilot who also commented on the turbulent conditions that were being experienced. The controller acknowledged the conditions and made a further offer of assistance should the pilot require it.

UVC was later observed on Williamtown Air Traffic Control radar to make a left turn to the south, depart the coastal VFR lane and head offshore.

According to Automatic Dependent Surveillance - Broadcast (ADS-B) data supplied by Airservices Australia, the helicopter's position at the beginning of the turn at 1811, was 2.3 km west-south-west of Anna Bay.

The aircraft continued to track offshore to the south-west for about 1 min 20 sec, maintaining between 3,000 and 3,600 ft before commencing a rapidly descending, left turn.

Surveillance data showed that the aircraft commenced this descent from 3,400 ft at about 1812:56, and the last data point identified the aircraft passing 525 ft at 1813:18.

ATSB
ATSB

Figure 2 shows the final flight segment based on ADS-B data, including the turn out to sea.

Two attempts by the Approach controller to contact the pilot at 1813 were unsuccessful.

The controller then broadcast advice to the pilot that surveillance identification had been lost and to immediately check altitude.

Further advice of the area's QNH[, the lowest safe altitude in the area, and an instruction to climb immediately were broadcast.

The controller followed that transmission with several more unsuccessful attempts to contact the pilot.

ATSB
ATSB

Recorded data

The aircraft was fitted with a Mode S transponder that broadcast ADS-B data.

This information included the position and altitude of the aircraft and was received by Airservices Australia as well as other third‑party ADS‑B receivers (Aireon and FlightRadar24) and provided to the ATSB.

Also on board were two mobile devices with the OzRunways application installed.

This application provides the option for live flight tracking by transmitting the device's position and altitude and that information was also obtained by the ATSB.

Site and wreckage

Initial indications of the possible location of the helicopter were found on the evening of 6 September at 1917.

Search personnel in aircraft reported an oil slick on the sea surface, about 5.5 km to the south-south-west of Anna Bay.

Two more oil slicks were observed that night in the same vicinity.

There were numerous reported sightings of possible helicopter wreckage that evening and the following morning with a small piece of floating wreckage, identified as part of the rear cabin lower bulkhead, retrieved by officers on a New South Wales Police Force search vessel on 7 September.

Two items that were also identified as wreckage from the helicopter subsequently washed ashore on Stockton Beach, and were collected by police on 18 September.

Following an extensive sea search, hampered by poor sea and weather conditions, the helicopter wreckage field was located on 26 September 2019. The wreckage field was situated about 5.4 km to the south-west of Anna Bay, in about 30 metres of water. A large section of the helicopter tailboom was recovered from the wreckage field for further examination

 

Pilot details

The pilot held Private and Commercial Pilot (Helicopter) Licences and was qualified to fly by day under the Visual Flight Rules.

The pilot also held a single-engine helicopter class rating and a gas turbine engine design feature endorsement.

The pilot last conducted a single-engine helicopter flight review in October 2018 that was valid until 31 October 2020.

His logbook indicated he had a total of 1,440.5 flying hours experience.

The pilot held a Class 1 aviation medical certificate that was valid until 26 Apr 2020.

 

Weather and available light

Forecast meteorological conditions for the Williamtown area for 6 September 2019 included moderate to severe turbulence and wind gusts up to 38 knots from the north-west from 1000.

From 1800, severe turbulence was forecast with wind gusts up to 45 knots occurring from the west-north-west and layers of scattered cloud at 4,000 ft and broken[8] cloud at 12,000 ft above ground level.

Light showers of rain were also forecast.

Comments between Williamtown Approach and Tower controllers at 1753 made reference to visibility in the area, which was noted to be about 6‑7 km.

Last light for the Anna Bay area, was calculated to occur at 1801 however, the presence of cloud cover, dust or masking terrain to the west would have resulted in last light occurring at an earlier time.

 

Further investigation

The investigation is continuing and will include examination of: meteorological conditions and pre‑flight preparation, pilot qualifications, experience and medical history, recovered aircraft wreckage, aircraft performance characteristics and recorded flight data, aircraft maintenance documentation and operational records, the provision of air traffic services.



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