At about 1708 Eastern Standard Time (EST) on 26 September 2002,
the pilot of a Piper PA-32-300 (Cherokee Six) aircraft, registered
VH-MAR, reported taxiing for departure from runway 14 at Hamilton
Island, Queensland. The charter flight was to Lindeman Island, a
distance of about 15 km to the southeast. On board the aircraft
were the pilot and five passengers.
Witnesses to the east of runway 14 at Hamilton Island reported
that, shortly after the aircraft became airborne, the engine began
coughing and misfiring, before cutting out and then starting again.
Shortly after, the aircraft commenced a right turn, and the engine
was heard spluttering and misfiring. Witnesses reported that, when
part way around the turn, the engine again cut out, and the
aircraft descended and impacted the ground.
The aircraft came to rest upright, aligned in an
east-north-easterly direction, approximately 300 m to the west of
the runway centreline and approximately 100 m south of the
departure end of the runway. A severe post-impact fire consumed the
majority of the aircrafts fuselage. The six occupants of the
aircraft were fatally injured.
The pilot was qualified, appropriately endorsed and authorised
for the operation. The pilots condition and demeanour on the day of
the occurrence were reported to be normal.
There was no evidence that fuel contamination, amount of fuel
carried, structural failure or meteorological conditions were
factors in the occurrence.
The engine installed in the aircraft was different from that
specified in the aircraft Type Certificate Data Sheet.
Notwithstanding, the Civil Aviation Safety Authority (CASA) and the
engine manufacturer reported that the installed engine should have
been capable of producing the power output expected from the engine
certified for installation in the Cherokee Six. Furthermore, the
engine had been in service in the aircraft for 126.2 flight hours
with no reported power abnormalities, suggesting that, provided
there were no defects, the engine should have been capable of
producing the required power throughout its operating range.
The extensive damage caused by the impact forces and post-impact
fire prevented functional testing of a significant number of
aircraft and engine components. On the available evidence, there
was nothing found to suggest what may have degraded the engine
performance to the extent reported by the witnesses to the
occurrence.
Post-mortem toxicological examination of the pilots blood
revealed a blood alcohol concentration (BAC) of 0.081%, the
presence of an inactive metabolite of cannabis, and an analgesic
preparation consistent with a therapeutic dosage. The possibility
that the pilots BAC reading resulted at least in part from
post-mortem alcohol production could not be discounted.
There was insufficient evidence to definitively link the pilots
prior intake of alcohol and/or cannabis with the occurrence.
However, the adverse effects on pilot performance of post-alcohol
impairment, recent cannabis use and fatigue could not be discounted
as contributory factors to the occurrence. In particular, the
possibility that the pilot experienced some degree of spatial
disorientation during the turn as a combined result of the
manoeuvre, associated head movements and alcohol-induced balance
dysfunction could not be discounted.
The following factors were considered to have significantly
contributed to the occurrence.
- Based on witness reports, the aircrafts engine commenced to
operate abnormally shortly after lift off from the runway. - The pilot initiated a steepening right turn at low level.
- The aircraft stalled at a height from which the pilot was
unable to effect recovery.
The operator has initiated a number of safety actions in order
to mitigate some of the issues identified in the report. Those
actions include the areas of: company pilot training, fatigue
management, documentation, and aircraft operations.
The ATSB has issued four recommendations concurrent with the
release of this report. The first three recommendations address the
potential use of alcohol and drugs by safety-sensitive personnel in
the Australian aviation industry, and options to manage the safety
risk to the travelling public of that potential use. The fourth
recommendation addresses the CASA Air Operator Certificate Safety
Trend Indicator surveillance methodology. In addition, two Safety
Advisory Notices have been issued to CASA relating to pilot
manipulation of the Cherokee Six fuel selector and development by
operators of pilot induction training programs.