Personnel information & licence details
The pilot had obtained a Commercial Pilot Licence in January
1996 followed by an Instructor Rating in August 1996. He was issued
with a Command Instrument Rating on 25 February 1998 and commenced
employment with the aircraft operator.
Flight experience & logbook entries to 19 July
1998
Total hours 1,013.5 (last 90 days 130.4)
Total command 778.7 (130.4)
Total dual 234.8
Total instructional flying 438.1
Multi-engine command 279.5 (130.4)
Instrument flight 43.5 (16.6)
Night 39.0 (12.9)
Last check 2-4 March 1998, initial route check by company chief
pilot
The pilot's logbook indicated that he had completed 22 GPS
arrival procedures since commencing operations at Wagga Wagga. This
included 15 GPS arrival procedures conducted while inbound to Wagga
Wagga, five of which were conducted in marginal weather conditions
with significant cloud below 1,500 ft above ground level.
The pilot had a normal rest pattern in the days preceding the
accident. There was no reported sleep disruption, evidence of
fatigue or other factors which might have affected his behaviour.
He had last worked 3 days prior to the day of the accident, on a
similar schedule to that of the accident flight.
During post-mortem toxicology testing of the pilot, low levels
of amphetamine and metabolites of anabolic steroids were detected.
Specialist advice indicated that the effects of such compounds were
extremely complex and the extent to which they may have influenced
the pilot's performance during the flight could not be
determined.
Observed weather conditions at Wagga Wagga
A meteorologist with the Bureau of Meteorology conducted an
aerodrome observation at Wagga Wagga shortly before the accident.
The wind was a light easterly with visibility reducing to 1,500 m
in light rain and mist. Significant cloud was observed in the
vicinity of the aerodrome and included 1 octa of stratus cloud at
300 ft above ground level and 5 octas of stratus at 600 ft above
ground level.
Wreckage and impact information
At the time of the collision with Gregadoo Hill the aircraft was
flying wings-level in an attitude consistent with level flight. The
main wreckage came to rest over the crest of the hill,
approximately 65 m beyond the initial point of impact.
The cockpit and cabin structure, including the wing centre
section, was destroyed. Post-impact fire substantially damaged both
wings. Damage to the propeller blades and their associated
assemblies was consistent with each engine operating under power at
the time of impact.
Aircraft information
The aircraft was equipped with two barometric pressure-sensitive
altimeters. The left altimeter was part of the pilot's standard
instrument panel. The second altimeter was located on the lower far
right of the co-pilot's instrument panel. Both altimeters separated
from the instrument panel during impact.
Although the internal mechanism of the pilot's left altimeter
had been substantially destroyed, it was possible to obtain the
setting of the altimeter sub-scale. Examination of the instrument
face did not reveal the presence of any witness marks and the
indicated altitude at the time of the accident could not be
determined.
The QNH set on the left altimeter sub-scale was 1013 hPa, which
corresponded with the forecast area QNH at the time of the
accident. The QNH information had been provided to the pilot by the
en-route controller. With that setting on the altimeter sub-scale,
the instrument would have indicated that the aircraft was
approximately 150 ft higher than it actually was. Although there
was a 5-hPa difference between the area QNH and the actual local
QNH at Wagga Wagga, it was within the normal amendment
criteria.
Components of the right altimeter were evident at the accident
site. The instrument face had been separated from the case and the
pre-impact altitude indication could not be determined, as there
were no witness marks evident. The QNH sub-scale was set to 1008
hPa. This setting corresponded with the departure aerodrome's QNH
and the actual QNH for Wagga Wagga at the time of the accident.
There was no automatic broadcast of weather information provided at
Wagga Wagga.
The aircraft pitot static system was extensively damaged during
the accident. The position of the selector valve for the alternate
static source could not be determined.
As there was an actual QNH available from the automatic terminal
information service at Albury, the pilot was required to conduct a
check of the aircraft's altimeters prior to takeoff. At least one
of the instruments was required to indicate within 60 ft of the
nominated elevation. An instrument indicating an error of more than
75 ft was to be placarded as unserviceable for flight under the
Instrument Flight Rules and an entry made in the aircraft
maintenance release to that effect. There was no evidence that
either of the aircraft altimeters was outside these tolerances in
the period leading up to the accident.
The ADF (navigation aid) receiver installed in the aircraft was
tuned to the frequency of the Wagga Wagga non-directional beacon.
The number one VOR (navigation aid) receiver was tuned to the
frequency of the Wagga Wagga VOR. The VOR omni-bearing selector was
set to a course of 013 degrees and this corresponded with the
published magnetic track between Albury and Wagga Wagga.
The aircraft's maintenance release was valid at the time of the
accident and no entries had been made in relation to outstanding
unserviceable items. It was reported that the pilot would inform
the chief pilot of any maintenance action required and that would
then be coordinated with the maintenance organisation. The aircraft
maintenance records contained no outstanding airworthiness
issues.
The investigation team was provided with a hand-written note
compiled by the pilot, which listed aircraft defects. The list was
to be supplied to the aircraft operator and maintenance
organisation for the next period of scheduled maintenance and
identified items that the pilot considered could require attention.
The team assessed the significance of the list and recovered some
components from the accident site for more detailed examination.
However, no evidence was available to suggest that the listed items
had contributed to the circumstances of the occurrence.
Global positioning system (GPS) and instrument
approach
The aircraft was equipped with a GPS satellite receiver and the
pilot broadcast on the mandatory broadcast zone frequency his
intention to conduct the Albury - Wagga Wagga GPS Arrival. This
procedure required the pilot to use distance information supplied
by the GPS receiver to conduct a progressive descent as the
aircraft approached the aerodrome. A ground-based navigation aid
provided azimuth guidance to the pilot. The aircraft's navigation
equipment was correctly configured for the procedure.
The last position recorded by the GPS receiver closely matched
the actual position of the accident site and indicated that the
aircraft had 4.20 NM to run to the aerodrome's VOR navigation aid.
The last altitude recorded on the GPS receiver was 1,274 ft. At
this stage of the approach procedure, the aircraft should not have
descended lower than 2,000 ft. Descent to the minimum descent
altitude (MDA) could then be made once the aircraft was within 3 NM
of the Wagga Wagga VOR.
The MDA published for the GPS instrument arrival procedure was
1,580 ft, with a required in-flight visibility of 2,400 m. Descent
to 1,580 ft would position the aircraft 856 ft above the aerodrome
elevation. Prior to departing Albury, the pilot had received the
latest weather report of broken cloud at 600 ft above ground level
and 2,000 m visibility in the vicinity of Wagga Wagga
aerodrome.
Before using the GPS receiver for operations under the
Instrument Flight Rules, the holder of an instrument rating was
required to complete a course of ground training to a specified
syllabus. No record was found of the pilot having completed this
training and the pilot's employer had provided no formal training
in the use of the GPS equipment installed on the aircraft. As the
GPS receiver was not equipped with a current data card, it was not
approved for use under the Instrument Flight Rules. The aircraft
was not equipped with alternative distance measuring equipment.