404 report Jandakot
Thread Starter
404 report Jandakot
FACTUAL INFORMATION
On 11 August 2003, at about 1537 Western Standard Time, a Cessna 404 Titan (C404) aircraft, registered VH-ANV, impacted terrain within the Jandakot Airport perimeter shortly after takeoff from runway 24 right and during an attempt by the pilot to return for an emergency landing. The aircraft was destroyed by the post-impact fire and one of the five passengers was fatally injured. The pilot and the other four passengers all received serious, life-threatening thermal injuries and one of those passengers died 85 days after the accident.
The C404 had been hired by a company contracted to the Royal Australian Navy. Specialised electronic and communications equipment had been installed for the flight, which was the first of a series scheduled for that week.
At about 1534 the Jandakot air traffic controller cleared the pilot for takeoff. A tower controller recalled that the initial part of the C404’s takeoff appeared normal. Shortly after the C404 became airborne, the controllers heard a change in the engine sound. This change was described as being similar to the sound when the power of one engine of a multi-engine aircraft is reduced during engine failure simulation. The controllers estimated that this occurred when the C404 was about 10 to 15 ft above the runway. They did not hear any surging, coughing or spluttering noises from the engines of the aircraft.
The pilot recalled that at about 50 to 100 ft above ground level, and as he reached down to initiate retraction of the landing gear, he noticed that he had to apply left rudder to prevent the aircraft nose from yawing. He recognised this as a symptom of an engine failure and positioned the landing gear selector “up”. He then selected the wing flaps to the “up” position and feathered the right engine’s propeller.
At about 1535 the pilot advised the controller that he had an emergency and indicated that he would be returning. Radar data indicated that the aircraft was at an altitude of approximately 200 ft (100 ft above airport elevation) about 300 m beyond the departure end of the runway and slightly to the right of the extended runway centreline. Radar records indicated the aircraft turned left shortly after the pilot made that transmission.
At about 1536 the pilot indicated that he would like to land on runway 12. The controller cleared the pilot to land. Radar records indicated that the aircraft continued its turn from the crosswind position and onto a slightly oblique downwind leg for runway 24. Radar data indicated that the C404’s altitude was about 200 ft. The last recorded radar data of the aircraft was as it approached the extended centreline for runway 30, at an altitude of about 200 ft. The ground track of the aircraft was approximately 030 degrees M.
Eyewitness reports were generally consistent with the information obtained from radar records. A number of eyewitnesses indicated that the aircraft was descending during the latter stages of the downwind leg of the circuit. Many witnesses reported seeing the aircraft’s nose gradually pitch-up during the final stages of the flight and as it descended towards the tree line. A large fireball was observed moments after the aircraft disappeared from view.
Local emergency services responded to the accident and extinguished the fire that was burning in the wreckage and surrounding terrain. The aircraft had been significantly consumed by fire and most components were severely fire damaged. The pilot and surviving passengers egressed the aircraft unaided. Local airport staff, nearby residents and trained medical personnel on duty at the airport provided assistance to the pilot and the surviving passengers.
Australian Transport Safety Bureau (ATSB) investigators attended the accident site to examine the aircraft wreckage. The aircraft had descended in a wings-level attitude into Banksia trees about 20 ft tall. The aircraft then slid a short distance before coming to rest. The outboard portion of the left wing was found detached from the main aircraft wreckage and along the swathe cut through the trees. The wing had separated inboard of the filler neck for the left fuel tank and this had ruptured the fuel tank. There was evidence that a significant quantity of fuel had spilled from the ruptured tank and ignited.
Wreckage removed for further examination and testing included the left and right engines and associated components, left and right propellers, various cockpit instruments/switches, and components from the aircraft's fuel system. Examination of the wreckage confirmed that the landing gear and wing flaps were in the retracted position at the time of impact.
The propellers and engines were examined in independent workshops under the direct supervision of ATSB investigators. Examination of the right propeller confirmed that the blades were in a feathered position at the time of impact. The blades of the left propeller were assessed as having been in the vicinity of the fine pitch stops at the time of impact. Detailed examination of the aircraft, engines and their systems was hampered by fire damage.
A review of data from the Bureau of Meteorology’s Automatic Weather Station for the time of the accident indicated a south-westerly wind of about 10 kts, temperature of 16 degrees Celsius and an atmospheric pressure of 1003 hectopascals. The Airservices Australia Automatic Terminal Information Service reported scattered cloud at 2,500 ft and visibility greater than 10 km.
The investigation examined fuel records for the day of the accident. These indicated that 651 L of AVGAS 100 from a mobile tanker were added to the C404 prior to the flight. Examination of other fuel records revealed no discrepancy, either with tanker meter readings or the totalised quantities of fuel delivered. ATSB commissioned an independent laboratory to test a sample of fuel from the tanker. Those tests confirmed that the fuel was aviation gasoline and complied with relevant industry standards. Due to the fire damage, it was not possible to obtain a fuel sample from the aircraft’s fuel system.
Preliminary assessment of the weight and balance indicates that the aircraft was loaded close to the maximum allowable take-off weight and within balance limits.
The investigation is continuing and includes examination and analysis of aircraft systems, aircraft performance, aerodrome factors, and the analysis of recorded radar data.
On 11 August 2003, at about 1537 Western Standard Time, a Cessna 404 Titan (C404) aircraft, registered VH-ANV, impacted terrain within the Jandakot Airport perimeter shortly after takeoff from runway 24 right and during an attempt by the pilot to return for an emergency landing. The aircraft was destroyed by the post-impact fire and one of the five passengers was fatally injured. The pilot and the other four passengers all received serious, life-threatening thermal injuries and one of those passengers died 85 days after the accident.
The C404 had been hired by a company contracted to the Royal Australian Navy. Specialised electronic and communications equipment had been installed for the flight, which was the first of a series scheduled for that week.
At about 1534 the Jandakot air traffic controller cleared the pilot for takeoff. A tower controller recalled that the initial part of the C404’s takeoff appeared normal. Shortly after the C404 became airborne, the controllers heard a change in the engine sound. This change was described as being similar to the sound when the power of one engine of a multi-engine aircraft is reduced during engine failure simulation. The controllers estimated that this occurred when the C404 was about 10 to 15 ft above the runway. They did not hear any surging, coughing or spluttering noises from the engines of the aircraft.
The pilot recalled that at about 50 to 100 ft above ground level, and as he reached down to initiate retraction of the landing gear, he noticed that he had to apply left rudder to prevent the aircraft nose from yawing. He recognised this as a symptom of an engine failure and positioned the landing gear selector “up”. He then selected the wing flaps to the “up” position and feathered the right engine’s propeller.
At about 1535 the pilot advised the controller that he had an emergency and indicated that he would be returning. Radar data indicated that the aircraft was at an altitude of approximately 200 ft (100 ft above airport elevation) about 300 m beyond the departure end of the runway and slightly to the right of the extended runway centreline. Radar records indicated the aircraft turned left shortly after the pilot made that transmission.
At about 1536 the pilot indicated that he would like to land on runway 12. The controller cleared the pilot to land. Radar records indicated that the aircraft continued its turn from the crosswind position and onto a slightly oblique downwind leg for runway 24. Radar data indicated that the C404’s altitude was about 200 ft. The last recorded radar data of the aircraft was as it approached the extended centreline for runway 30, at an altitude of about 200 ft. The ground track of the aircraft was approximately 030 degrees M.
Eyewitness reports were generally consistent with the information obtained from radar records. A number of eyewitnesses indicated that the aircraft was descending during the latter stages of the downwind leg of the circuit. Many witnesses reported seeing the aircraft’s nose gradually pitch-up during the final stages of the flight and as it descended towards the tree line. A large fireball was observed moments after the aircraft disappeared from view.
Local emergency services responded to the accident and extinguished the fire that was burning in the wreckage and surrounding terrain. The aircraft had been significantly consumed by fire and most components were severely fire damaged. The pilot and surviving passengers egressed the aircraft unaided. Local airport staff, nearby residents and trained medical personnel on duty at the airport provided assistance to the pilot and the surviving passengers.
Australian Transport Safety Bureau (ATSB) investigators attended the accident site to examine the aircraft wreckage. The aircraft had descended in a wings-level attitude into Banksia trees about 20 ft tall. The aircraft then slid a short distance before coming to rest. The outboard portion of the left wing was found detached from the main aircraft wreckage and along the swathe cut through the trees. The wing had separated inboard of the filler neck for the left fuel tank and this had ruptured the fuel tank. There was evidence that a significant quantity of fuel had spilled from the ruptured tank and ignited.
Wreckage removed for further examination and testing included the left and right engines and associated components, left and right propellers, various cockpit instruments/switches, and components from the aircraft's fuel system. Examination of the wreckage confirmed that the landing gear and wing flaps were in the retracted position at the time of impact.
The propellers and engines were examined in independent workshops under the direct supervision of ATSB investigators. Examination of the right propeller confirmed that the blades were in a feathered position at the time of impact. The blades of the left propeller were assessed as having been in the vicinity of the fine pitch stops at the time of impact. Detailed examination of the aircraft, engines and their systems was hampered by fire damage.
A review of data from the Bureau of Meteorology’s Automatic Weather Station for the time of the accident indicated a south-westerly wind of about 10 kts, temperature of 16 degrees Celsius and an atmospheric pressure of 1003 hectopascals. The Airservices Australia Automatic Terminal Information Service reported scattered cloud at 2,500 ft and visibility greater than 10 km.
The investigation examined fuel records for the day of the accident. These indicated that 651 L of AVGAS 100 from a mobile tanker were added to the C404 prior to the flight. Examination of other fuel records revealed no discrepancy, either with tanker meter readings or the totalised quantities of fuel delivered. ATSB commissioned an independent laboratory to test a sample of fuel from the tanker. Those tests confirmed that the fuel was aviation gasoline and complied with relevant industry standards. Due to the fire damage, it was not possible to obtain a fuel sample from the aircraft’s fuel system.
Preliminary assessment of the weight and balance indicates that the aircraft was loaded close to the maximum allowable take-off weight and within balance limits.
The investigation is continuing and includes examination and analysis of aircraft systems, aircraft performance, aerodrome factors, and the analysis of recorded radar data.
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CFI
Couldn't agree more.
Hindsight is always 20:20 and maybe the golf course would have been the destination of choice if one had a real inkling of the problem at hand.
The other 120 litres burnt like the 650 litres from the tanker but there must be some way of tracing what it was and where it came from.
Couldn't agree more.
Hindsight is always 20:20 and maybe the golf course would have been the destination of choice if one had a real inkling of the problem at hand.
The other 120 litres burnt like the 650 litres from the tanker but there must be some way of tracing what it was and where it came from.
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You have to wonder why they did not take samples from the sand. You could store a million litres in that stuff. Everythnig I have heard, including a eyewitness points to fuel problems as a primary cause. Plus the delay in getting fire services to them and getting to work. But hey, it was not any of the people who matter who got barbequed, so why should they care if others pay for their cost savings.
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farqueue
It amazes me that you suggest our fire services are mediocre, and actively ignoring a life threatening situation. You have never been in an emergengy response position, obviously. Sure nothing is perfect, and we all know that in aviation. I suggest stick to the facts, not the rumours.
What has happened was an accident, a terrible one, we don´t yet know the real cause...but be assured many people involved will want to know the reality of the situation...so hopefully we all learn a thing or two and future accidents may be avoided.
Your comments do not help.
It amazes me that you suggest our fire services are mediocre, and actively ignoring a life threatening situation. You have never been in an emergengy response position, obviously. Sure nothing is perfect, and we all know that in aviation. I suggest stick to the facts, not the rumours.
What has happened was an accident, a terrible one, we don´t yet know the real cause...but be assured many people involved will want to know the reality of the situation...so hopefully we all learn a thing or two and future accidents may be avoided.
Your comments do not help.
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Travelair, I have had 8 years as a firey, and can take you to see the ex JT fire tender, and show you why a standard fireengine is not suitable for AC fire fighting. When the times to respond are released, you will see that the time to get there is a further issue.
Add to the casualties in the plane, there guys who busted a gut to try to do the imposible.
But, hey, this is cost effective, right? How many have died in fires at GAAP airfields since the AFFRS has been withdrawn?
Add to the casualties in the plane, there guys who busted a gut to try to do the imposible.
But, hey, this is cost effective, right? How many have died in fires at GAAP airfields since the AFFRS has been withdrawn?
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Farqueue
I retract on my assumption of your background...and I agree the situation is compounded by not having AFFRS at the airport. It just seemed like you were banging the guys, not the system they battle in.
How can we get AFFRS back on site? More taxes? A user levy? Unfortunately things do sometimes come down to money. I would suggest less money into defence...
Back to this topic, though, and there is no conclusion yrt on what actually happened. Lots of things could have been done in retrospect, as is always the case. Im just very sorry it all happened.
I retract on my assumption of your background...and I agree the situation is compounded by not having AFFRS at the airport. It just seemed like you were banging the guys, not the system they battle in.
How can we get AFFRS back on site? More taxes? A user levy? Unfortunately things do sometimes come down to money. I would suggest less money into defence...
Back to this topic, though, and there is no conclusion yrt on what actually happened. Lots of things could have been done in retrospect, as is always the case. Im just very sorry it all happened.
Second hand information given to me was that the RAC (not Royal Aero CLub) B412 was stopped from proceeding to the sight by certain people at JT. If that is true, they ought to be strung up.
Any of the SAR crew care to comment?
Any of the SAR crew care to comment?
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There still seems to be a general reluctance to advise where the remainder of the fuel on that flight came from
One has to wonder why it was spewing black smoke as it went over the fence and the guy driving was so compromised
One has to wonder why it was spewing black smoke as it went over the fence and the guy driving was so compromised
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captain marvellous has the basic fact right.
Lose an engine at liftoff anywhere near max gross in an FAR 23 aircraft and you will be exceedingly lucky to survive, even doing everything by the book, as this unfortunate driver would appear to have done. Perhaps the only salvation land straight ahead, but who would do that if there is even a remote chance of getting back without breaking anything. Not an easy choice and thankfully one that very few people have to face.
Prospector
Lose an engine at liftoff anywhere near max gross in an FAR 23 aircraft and you will be exceedingly lucky to survive, even doing everything by the book, as this unfortunate driver would appear to have done. Perhaps the only salvation land straight ahead, but who would do that if there is even a remote chance of getting back without breaking anything. Not an easy choice and thankfully one that very few people have to face.
Prospector
Thread Starter
The aircraft was lower than the High Tension Power Lines located of the end of runway 24.
Hence the reason for not continuing straight ahead.
The reason the aircraft turned left was to avoid the built up areas to the western side of the circuit
Hence the reason for not continuing straight ahead.
The reason the aircraft turned left was to avoid the built up areas to the western side of the circuit
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Traffic
"spewing black smoke..." was that from the exhaust or the engine surroundings. What do you mean/suggest? Fuel giving off black smoke? or a bust oil line near the waste gate, hence burning oil fumes? See the thing is that we can go forever speculating. Where is this thread going?
"spewing black smoke..." was that from the exhaust or the engine surroundings. What do you mean/suggest? Fuel giving off black smoke? or a bust oil line near the waste gate, hence burning oil fumes? See the thing is that we can go forever speculating. Where is this thread going?
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Bearing in mind that the report states
I doubt that an airport based fire service would have made any difference. A little research through the available australian & international aviation accident databases shows no demonstrated benefit from having GA-airport based RFFS; fact is, if it crashes and burns, it's all over red rover in a matter of minutes or less. If it doesn't burn, then on on-site medical facility would be of more benefit than a RFFS.
Just an opinion, based on experience from both sides of the fence.
As for the helicopter, they are pointless in this situation unless they have medical crewing - did the (not-yet-in-service) B412 at JT have medical crewing at the time?
A large fireball was observed moments after the aircraft disappeared from view.
Just an opinion, based on experience from both sides of the fence.
As for the helicopter, they are pointless in this situation unless they have medical crewing - did the (not-yet-in-service) B412 at JT have medical crewing at the time?
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I have not walk out to have a look myself, but I believe the crash was in fact at the edge of the clearing that used to be used for hot fire training. Drowning would have been the risk if the AFRSS was still there! They
would have been on it in seconds.
The 412 was doing drills with RFDS and the hospitals to get their systems co-ordinated, and to test the systems with the hospitals that where put in place post Bali. Every man and is orderly who could come up with an excuse to be there was. Including between 2-3 full crews for the AA, plus other medics.
would have been on it in seconds.
The 412 was doing drills with RFDS and the hospitals to get their systems co-ordinated, and to test the systems with the hospitals that where put in place post Bali. Every man and is orderly who could come up with an excuse to be there was. Including between 2-3 full crews for the AA, plus other medics.
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Previous posts here refer to: "120 l" of fuel. I don't see any reference to this in the report and don't know what ithey are based on but the 651 l mentioned was obviously added by the tanker, as per the report.
Seems fair to say that any additional fuel burnt in the post-impact fire was already in the tanks as, un-burnt reserves, surplus, etc from the previous flight. Seems obvious to me but maybe I'm missing something here.
Seems fair to say that any additional fuel burnt in the post-impact fire was already in the tanks as, un-burnt reserves, surplus, etc from the previous flight. Seems obvious to me but maybe I'm missing something here.
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So we should pay extra for RFFS and make sure if we crash we do so in an area that they can readily access .....and we should have a medically crewed helicopter on running standby at $2500.00/hr at all GA or GAAP aerodromes whenever flight ops are in progress....is that the idea?
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swh, I was refering to Royal Flying Doctor Service. They have not gone and changed their bloody name have they?
The AFRSS is not only responsible for on AP fire fighting, but also responds to crashes off airport. So if there was a major crash there would now be only Perth's crews available. I'm not sure if FESA still have their foam tanker. They have been wanting to dump it for years and a cut back on the airports would be just the excuse they need.
The AFRSS is not only responsible for on AP fire fighting, but also responds to crashes off airport. So if there was a major crash there would now be only Perth's crews available. I'm not sure if FESA still have their foam tanker. They have been wanting to dump it for years and a cut back on the airports would be just the excuse they need.