Investigation number
199003089
Occurrence date
State
Queensland
Report release date
Report status
Final
Investigation type
Occurrence Investigation
Investigation status
Completed
Aviation occurrence type
Collision with terrain
Occurrence category
Accident
Highest injury level
Fatal

CIRCUMSTANCES: "The aircraft was conducting a night DEPARTURE from Runway 36 at Wondai, Queensland. After an apparently normal take-off, it struck the ground 600 metres beyond the end of the runway in a shallow, wings level descent and at high speed. The aircraft was destroyed by impact forces and fire, and five of the six occupants on board were killed. 3. FINDINGS 3.1 The pilot was medically fit, correctly licenced and qualified to undertake the flight. 3.2 There were no significant meteorological conditions existing at the time of the accident, but the night was dark with no moon and no visible horizon. 3.3 There was evidence of influences which could have resulted in the pilot experiencing the effects of fatigue and/or stress at the time of the accident. 3.4 The pilot received no formal ""human factors"" education during his instrument flying training. 3.5 The aircraft became airborne after a take-off roll of about 900 metres and probably reached a height of about 70 feet (21 metres) above the level of the runway before commencing a shallow descent. 3.6 The pilot transmitted an airborne call very soon after lift-off. 3.7 The aircraft speed at impact was approximately 183 knots. 3.8 The aircraft was in controlled flight, wings level and in a shallow descent at impact. 3.9 The aircraft landing gear and flaps were in the retracted position at impact. 3.10 No evidence was found that the aircraft was not capable of normal operation at the time of the accident. 4. FACTORS The circumstances leading to the development of this accident could not be established conclusively. However, the evidence supports the following as probable factors 4.1 The pilot might not have been aware of the human factors aspects associated with dark night take-offs. 4.2 The pilot could have been influenced by stress and/or fatigue. 4.3 The aircraft was taking off towards dark textureless terrain and no visible horizon. 4.4 By transmitting his airborne call very soon after lift-off, the pilot was not devoting his full attention to flying the aircraft. 4.5 The pilot became disorientated and placed the aircraft in a shallow descent as it accelerated after take-off. 5. SAFETY ACTION A search of the Bureau's records revealed a number of accidents with circumstances generally similar to this accident. With some exceptions, a pattern emerged in which total pilot experience was moderate to high but hours on type were comparatively low. Pilot age was typically 40-60 years. The Bureau is undertaking a detailed analysis of these accidents with the aim, among others, of producing a profile of the ""at risk"" pilot. The results of the study will be published in the BASI Journal. Some other aspects of this accident have also been identified as areas which warrant further research. These include 5.1 Instrument rating tests and their effectiveness, particularly in such areas as the transition from visual to instrument flight and test effectiveness when conducted in aircraft of significantly lower performance than that normally flown by the pilot. 5.2 The training methods used in night take-off/no visible horizon situations their effectiveness." RECCOMENDATIONS: 6.1 It is expected that at least one safety enhancement recommendation will be made as a result of this investigation.

Aircraft Details
Manufacturer
Beech Aircraft Corp
Model
E90
Registration
VH-LFH
Sector
Turboprop
Departure point
WONDAI QLD
Destination
CAMDEN NSW
Damage
Destroyed