ASN Wikibase Occurrence # 233865
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| Date: | Wednesday 11 March 2020 |
| Time: | 09:19 |
| Type: |  Cessna 404 Titan |
| Owner/operator: | Air Connect Australia |
| Registration: | VH-OZO |
| MSN: | 404-0653 |
| Year of manufacture: | 1980 |
| Total airframe hrs: | 28193 hours |
| Engine model: | Teledyne-continental TSIO-520-M |
| Fatalities: | Fatalities: 5 / Occupants: 5 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | 6,4 km SE of Lockhart River Airport, QLD (IRG/YLHR) -
 Australia
|
| Phase: | Approach |
| Nature: | Passenger - Non-Scheduled/charter/Air Taxi |
| Departure airport: | Cairns Airport, QLD (CNS/YBCS) |
| Lockhart River Airport, QLD (IRG/YLHR) | |
| Investigating agency: | ATSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
The Cessna 404 aircraft, registered VH-OZO, was being operated by Air Connect Australia to conduct a passenger charter flight from Cairns to Lockhart River, Queensland, Australia. On board were the pilot and 4 passengers, and the flight was being conducted under the instrument flight rules (IFR).
Consistent with the forecast, there were areas of cloud and rain that significantly reduced visibility at Lockhart River Airport. On descent, the pilot obtained the latest weather information from the airport’s automated weather information system (AWIS) and soon after commenced an area navigation (RNAV) global satellite system (GNSS) instrument approach to runway 30.
The pilot conducted the first approach consistent with the recommended (3°) constant descent profile, and the aircraft kept descending through the minimum descent altitude (MDA) of 730 ft and passed the missed approach point (MAPt). At about 400 ft, the pilot commenced a missed approach.
After conducting the missed approach, the pilot immediately commenced a second RNAV GNSS approach to runway 30.
During this approach, the pilot commenced descent from 3,500 ft about 2.7 NM prior to the intermediate fix (or 12.7 NM prior to the MAPt). The descent was flown at about a normal 3° flight path, although about 1,000 ft below the recommended descent profile. While continuing on this descent profile, the aircraft descended below the MDA. It then kept descending until it collided with terrain 6.4 km (3.5 NM) short of the runway. The pilot and 4 passengers were fatally injured, and the aircraft was destroyed.
Contributing factors
- While the pilot was operating in the vicinity of Lockhart River Airport, there were areas of cloud and rain that significantly reduced visibility and increased the risk of controlled flight into terrain. In particular, the aircraft probably entered areas of significantly reduced visibility during the second approach.
- After an area navigation (RNAV) global satellite system (GNSS) approach to runway 30 and missed approach, the pilot immediately conducted another approach to the same runway that was on a similar gradient to the recommended descent profile but displaced about 1,000 ft below that profile. While continuing on this descent profile, the aircraft descended below a segment minimum safe altitude and the minimum descent altitude, then kept descending until the collision with terrain about 6 km before the runway threshold.
- Although the exact reasons for the aircraft being significantly below the recommended descent profile and the continued descent below the minimum descent altitude could not be determined, it was evident that the pilot did not effectively monitor the aircraft’s altitude and descent rate for an extended period.
- When passing the final approach fix (FAF), the aircraft’s lateral position was at about full-scale deflection on the course deviation indicator (CDI), and it then exceeded full-scale deflection for an extended period. In accordance with the operator’s stabilised approach procedures, a missed approach should have been conducted if the aircraft exceeded half full-scale deflection at the FAF, however a missed approach was not conducted.
- The pilot was probably experiencing a very high workload during periods of the second approach. In addition to the normal high workload associated with a single pilot hand flying an approach in instrument meteorological conditions, the pilot’s workload was elevated due to conducting an immediate entry into the second approach, conducting the approach in a different manner to their normal method, the need to correct lateral tracking deviations throughout the approach, and higher than appropriate speeds in the final approach segment.
- The aircraft was not fitted with a terrain avoidance and warning system (TAWS). Such a system would have provided visual and aural alerts to the pilot of the approaching terrain for an extended period, reducing the risk of controlled flight into terrain.
- Although the aircraft was fitted with a GPS/navigational system suitable for an area navigation (RNAV) global satellite system (GNSS) approach and other non-precision approaches, it was not fitted with a system that provided vertical guidance information, which would have explicitly indicated that the aircraft was well below the recommended descent profile.
- Although the operator had specified a flight profile for a straight-in approaches and stabilised approach criteria in its operations manual, and encouraged the use of stabilised approaches, there were limitations with the design of these procedures. In addition, there were limitations with other risk controls for minimising the risk of controlled flight into terrain (CFIT), including no procedures or guidance for the use of the terrain awareness function on the aircraft’s GNS 430W GPS/navigational units and limited monitoring of the conduct of line operations. (Safety Issue)
Accident investigation:
 |
|
Sources:
https://www.theaustralian.com.au/nation/lockhart-river-plane-crash-five-feared-dead-in-cape-york-flight-disaster/news-story/9e0d5b22c009b8e694bcd07d45d120ce
https://www.9news.com.au/national/queensland-plane-crash-lockhart-river-far-north/a7d03e3e-67de-472f-901d-b267333caca1
https://www.abc.net.au/news/2020-03-11/lockhart-river-search-plane-crash-beach-qld/12046400
Data _______________________________
https://flightaware.com/live/flight/VHOZO
https://www.flickr.com/photos/143294701@N04/33977403212/ (Photo)
ATSB _______________________________
https://www.atsb.gov.au/publications/investigation_reports/2020/aair/ao-2020-017/
Location
Images:
Photo: ATSB
Media:
The ATSB will investigate this morning's accident involving a Cessna 404 aircraft near Lockhart River, Queensland. pic.twitter.com/HNJHZdbULB
— ATSB (@atsbgovau) March 11, 2020
BREAKING: Five people have died following a light plane crash in remote Far North Queensland. Police have discovered the wreckage of the aircraft on a beach near the Lockhart River Airstrip. #7NEWS https://t.co/9XJdWdribW
— 7NEWS Townsville (@7NewsTownsville) March 11, 2020
This is the Lockhart River crash site.
— Adam Hegarty (@ajhegarty9) March 12, 2020
The plane hit a sand dune in low cloud. Friends of the five on board are heartbroken - as is the remote community. @9NewsQueensland pic.twitter.com/HfY1USEbos
UPDATE: Five men have been killed after a light plane crashed near the Lockhart River in Far North Queensland.
— Katarina Stefanovic (@KatStefanovic) March 11, 2020
Police will help the Australian Transport Safety Bureau examine the wreckage. @9newsqueensland @9NewsFarNthQld pic.twitter.com/lXRLa0DIEO
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 11-Mar-2020 05:18 | Captain Adam | Added |
| 11-Mar-2020 06:53 | harro | Updated [Departure airport, Destination airport] |
| 11-Mar-2020 06:55 | B777 | Updated [Total fatalities, Phase, Departure airport, Destination airport, Source, Narrative] |
| 11-Mar-2020 06:56 | harro | Updated [Location, Nature] |
| 11-Mar-2020 07:39 | RobertMB | Updated [Operator, Source] |
| 11-Mar-2020 18:05 | RobertMB | Updated [Time, Operator, Source, Narrative] |
| 11-Mar-2020 20:16 | Iceman 29 | Updated [Source, Embed code, Photo] |
| 12-Mar-2020 13:55 | Captain Adam | Updated [Operator, Location, Source, Embed code, Narrative] |
| 12-Mar-2020 16:20 | Iceman 29 | Updated [Source, Embed code] |
| 12-Mar-2020 16:21 | Iceman 29 | Updated [Embed code] |
| 26-Mar-2020 08:02 | Anon. | Updated [Embed code, Narrative] |
| 10-Mar-2021 20:25 | harro | Updated [Photo] |
| 08-May-2021 16:59 | harro | Updated [Operator, Source] |
| 08-May-2021 17:00 | harro | Updated [[Operator, Source]] |
| 04-May-2022 09:44 | Anon. | Updated [Narrative] |
| 02-Nov-2023 18:20 | harro | Updated [[Narrative]] |
| 22-Nov-2023 20:06 | harro | Updated [Other fatalities, Accident report] |
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