Incident Overview

Date: Tuesday 29 October 1991
Aircraft Type: Boeing 707-368C
Owner/operator: Royal Australian Air Force – RAAF
Registration Number: A20-103
Location: 43 km S off East Sale, VIC, Australia – ÿ Pacific Ocean
Phase of Flight: En route
Status: Destroyed, written off
Casualties: Fatalities: 5 / Occupants: 5
Component Affected: 707 aircraft.707 aircraft.
Category: Accident
A Boeing 707 stalled and crashed into the sea due to a simulation of asymmetric flight. The instructor’s demonstration of this flight pattern was deemed inherently dangerous and resulted in a sudden departure from controlled flight, leading to the aircraft’s loss. The incident highlights deficiencies in RAAF 707 operational knowledge, documentation, and training procedures.A Boeing 707 stalled and crashed into the sea due to a simulation of asymmetric flight. The instructor’s demonstration of this flight pattern was deemed inherently dangerous and resulted in a sudden departure from controlled flight, leading to the aircraft’s loss. The incident highlights deficiencies in RAAF 707 operational knowledge, documentation, and training procedures.

Description

The RAAF Boeing 707 stalled and crashed into the sea. The crash was attributed to a simulation of asymmetric flight resulting in a sudden and violent departure from controlled flight. The Board of Inquiry concluded that the instructor devised a demonstration of asymmetric flight that was ‘inherently dangerous and that was certain to lead to a sudden departure from controlled flight’ and that he did not appreciate this. The Board noted there were deficiencies in the acquisition and documentation of 707 operational knowledge within the RAAF combined with the absence of effective mechanisms to prevent the erosion of operational knowledge at a time when large numbers of pilots were resigning from the air force. There was no official 707 QFI conversion course and associated syllabus and no adequate QFI instructors’ manual. There were deficiencies in the documented procedures and limitations pertaining to asymmetric flight in the 707 and a lack of fidelity in the RAAF 707 simulator in the flight regime in which the accident occurred, which, assuming such a requirement existed, required actual practise in flight. ‘The captain acted with the best of intentions but without sufficient professional knowledge or understanding of the consequences of the situation in which he placed the aircraft,’ the Board said.

Primary Cause

Simulation of asymmetric flight.Simulation of asymmetric flight.

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