Investigation number
199901850
Occurrence date
Location
Lakr Neale
Report release date
Report status
Final
Investigation type
Occurrence Investigation
Investigation status
Completed
Aviation occurrence type
Lost/unsure of position
Occurrence category
Incident
Highest injury level
None

The pilot was conducting a night freight operation, carrying
newspapers from Darwin to Alice Springs via Tindal and Tennant
Creek. The flight from Darwin to Tindal was uneventful and the
aircraft subsequently departed Tindal at 0219 am local time.

On departure, the pilot reported that he mistakenly established
the aircraft on a track 30 degrees right of the correct track.
After the pilot had levelled the aircraft at the intended cruising
altitude, he fell asleep. As the flight progressed, the pilot
occasionally woke up and made slight corrections to the heading,
but he did not identify the 30 degree error. When the pilot
realised that he should be on descent to Tennant Creek, he selected
the appropriate frequencies, however the aircraft's navigation
instruments did not provide any directional information. Believing
that the aircraft was west of Tennant Creek, the pilot turned the
aircraft and flew east, climbing to 14000 ft in an attempt to
improve the range of the aircraft's navigation instruments. The
instruments still did not show where Tennant Creek was, so the
pilot decided to continue to Alice Springs at his flight planned
altitude. At the time that the aircraft should have been
approaching Alice Springs, the pilot selected the appropriate
frequencies for the Alice Springs navigation aids. The aircraft's
navigation instruments did not indicate the direction of Alice
Springs, even though the pilot again climbed the aircraft to 14000
ft. The pilot reported that as the aircraft was now running low on
fuel, the pilot decided to conduct a precautionary search and
landing. The pilot advised Adelaide Flight Service on high
frequency radio that he intended to land the aircraft on a dry salt
lake.

The aircraft sustained minor damage during the landing however
the pilot was not injured. He then activated the Emergency Locater
Transmitter, and the aircraft was subsequently located 370 km WSW
of Alice Springs. The company reported that its roster for night
freight pilots has operated satisfactorily for around four years,
with no reported serious fatigue problems. The pilots usually
operate a one night shift every eight days, and the three days
before the night shift are either days off or standby days. The
pilot involved in this incident had done no flying on his rostered
standby day, and therefore had had three full days off prior to
signing on late in the evening of the day before the accident. He
stated that he normally tried to sleep in on the morning before the
night shift, and then get a couple of hours sleep in the
afternoon.However, on the morning before he signed on for the night
flight he was unable to sleep in and was then also unable to sleep
in the afternoon. Consequently, by the time he signed on for the
flight, the pilot had been awake for approximately 13.5 hours. The
aircraft was not equipped with GPS. It is probable that the pilot's
lack of sleep prior to signing on for the flight resulted in an
increased level of fatigue. The increased fatigue may have
contributed to the pilot selecting the incorrect heading on
departure from Tindal and his subsequent lapses into sleep. Once
the aircraft was out of range of the Tennant Creek and Alice
Springs navigation aids and because of the lack of terrain features
visible at night, there was no information available to the pilot
to help him identify his position. The company is currently
ensuring that flight crews have access to GPS equipment. The
company is also drafting detailed standard operating procedures
regarding sleep management, and these procedures will be included
in the operations manual.

Aircraft Details
Manufacturer
Cessna Aircraft Company
Model
210
Registration
VH-NQP
Operation type
Charter
Departure point
Tindal NT
Destination
Tennant Creek NT
Damage
Nil