Douglas C-47A-20-DK (DC-3) – VH-EDC

Incident Overview

Date: Sunday 24 April 1994

Aircraft Type: Douglas C-47A-20-DK (DC-3)

Owner/operator: South Pacific Airmotive

Registration Number: VH-EDC

Location: 0,1 km S off Sydney-Kingsford Smith International Airport, NSW (SYD) – ÿ Australia

Phase of Flight: Initial climb

Status: Destroyed, written off

Casualties: Fatalities: 0 / Occupants: 25

Component Affected: UnknownUnknown

Investigating Agency: BASIBASI

Category: Accident

On July 12, 2023, a South Pacific Airmotive Douglas DC-3 crashed into the water near Norfolk Island Airport, NSW, Australia, resulting in the loss of 25 lives. All 25 occupants survived the accident. The aircraft, VH-EDC, was chartered to transport college students and their band equipment to Anzac Day celebrations on Norfolk Island. The flight was scheduled to proceed from Sydney (SYD) to Norfolk Island, with an intermediate landing at Lord Howe Island Airport (LDH) to refuel. The flight was to be conducted in accordance with IFR procedures, and the aircraft was cleared for takeoff at 09:07:53. The co-pilot, the handling pilot, was the designated pilot for the departure. The aircraft was cleared for takeoff at 09:07:53. The aircraft, carrying 21 passengers, was crewed by two pilots, a supernumerary pilot, and a flight attendant. Shortly after takeoff, the aircraft experienced a series of alarming events. The pilot in command initially advised the Tower that the aircraft had a problem, and the co-pilot determined that the left engine was malfunctioning. The aircraft speed increased to at least 100 kts, and the aircraft began to yaw left. The pilot in command closed the left throttle and initiated propeller feathering, but the airspeed decreased. The co-pilot reported that he was unable to maintain 81 kts, and the aircraft diverged to the left of the runway centerline. The pilot in command then took control, and advised the Tower that the aircraft was capable of climbing safely on one engine. The aircraft was ditched approximately 46 seconds after the pilot in command first advised the Tower of the problem, and four crew members and 21 passengers successfully evacuated the aircraft. The investigation revealed a critical issue: a significant power loss in the left engine, compounded by a stuck inlet valve, leading to a combination of local and organizational factors. These factors included the aircraft’s overweight condition, an engine overhaul error, inadequate operational procedures, and a lack of skilled piloting. Organizational factors centered around inadequate communications between South Pacific Airmotive Pty Ltd and Groupair, a lack of maintenance management, poor operational procedures, and inadequate control and monitoring of South Pacific Airmotive. The regulator’s role was inadequate in communication and oversight, with insufficient oversight of the South Pacific Airmotive and a failure to effectively manage communications between Civil Aviation Authority and Groupair/South Pacific Airmotive. These factors contributed to the accident. The incident underscores the importance of robust maintenance, effective communication, and comprehensive training within aviation operations.On July 12, 2023, a South Pacific Airmotive Douglas DC-3 crashed into the water near Norfolk Island Airport, NSW, Australia, resulting in the loss of 25 lives. All 25 occupants survived the accident. The aircraft, VH-EDC, was chartered to transport college students and their band equipment to Anzac Day celebrations on Norfolk Island. The flight was scheduled to proceed from Sydney (SYD) to Norfolk Island, with an intermediate landing at Lord Howe Island Airport (LDH) to refuel. The flight was to be conducted in accordance with IFR procedures, and the aircraft was cleared for takeoff at 09:07:53. The co-pilot, the handling pilot, was the designated pilot for the departure. The aircraft was cleared for takeoff at 09:07:53. The aircraft, carrying 21 passengers, was crewed by two pilots, a supernumerary pilot, and a flight attendant. Shortly after takeoff, the aircraft experienced a series of alarming events. The pilot in command initially advised the Tower that the aircraft had a problem, and the co-pilot determined that the left engine was malfunctioning. The aircraft speed increased to at least 100 kts, and the aircraft began to yaw left. The pilot in command closed the left throttle and initiated propeller feathering, but the airspeed decreased. The co-pilot reported that he was unable to maintain 81 kts, and the aircraft diverged to the left of the runway centerline. The pilot in command then took control, and advised the Tower that the aircraft was capable of climbing safely on one engine. The aircraft was ditched approximately 46 seconds after the pilot in command first advised the Tower of the problem, and four crew members and 21 passengers successfully evacuated the aircraft. The investigation revealed a critical issue: a significant power loss in the left engine, compounded by a stuck inlet valve, leading to a combination of local and organizational factors. These factors included the aircraft’s overweight condition, an engine overhaul error, inadequate operational procedures, and a lack of skilled piloting. Organizational factors centered around inadequate communications between South Pacific Airmotive Pty Ltd and Groupair, a lack of maintenance management, poor operational procedures, and inadequate control and monitoring of South Pacific Airmotive. The regulator’s role was inadequate in communication and oversight, with insufficient oversight of the South Pacific Airmotive and a failure to effectively manage communications between Civil Aviation Authority and Groupair/South Pacific Airmotive. These factors contributed to the accident. The incident underscores the importance of robust maintenance, effective communication, and comprehensive training within aviation operations.

Description

A South Pacific Airmotive Douglas DC-3 crashed into the water shortly after takeoff from Sydney-Kingsford Smith Airport, NSW, Australia; all 25 occupants survived the accident. The DC-3 aircraft VH-EDC had been chartered to convey college students and their band equipment from Sydney (SYD) to Norfolk Island Airport (NLK) to participate in Anzac Day celebrations on the island. The aircraft was to proceed from Sydney (Kingsford-Smith) Airport to Norfolk Island, with an intermediate landing at Lord Howe Island Airport, NSW (LDH) to refuel. The flight was to be conducted in accordance with IFR procedures. The aircraft, which was carrying 21 passengers, was crewed by two pilots, a supernumerary pilot and a flight attendant. Preparations for departure were completed shortly before 09:00, and the aircraft was cleared to taxi for runway 16 via taxiway Bravo Three. The co-pilot was the handling pilot for the departure. The aircraft was cleared for takeoff at 09:07:53. All engine indications were normal during the takeoff roll and the aircraft was flown off the runway at 81 kts. During the initial climb, at approximately 200 ft, with flaps up and the landing gear retracting, the crew heard a series of popping sounds above the engine noise. Almost immediately, the aircraft began to yaw left and at 09:09:04 the pilot in command advised the Tower that the aircraft had a problem. The co-pilot determined that the left engine was malfunctioning. The aircraft speed at this time had increased to at least 100 kts. The pilot in command, having verified that the left engine was malfunctioning, closed the left throttle and initiated propeller feathering action. During this period, full power (48 inches Hg and 2,700 RPM) was maintained on the right engine. However, the airspeed began to decay. The co-pilot reported that he had attempted to maintain 81 KIAS but was unable to do so. The aircraft diverged to the left of the runway centreline. Almost full right aileron had been used to control the aircraft. The copilot reported that he had full right rudder or near full right rudder applied. When he first became aware of the engine malfunction, the pilot in command assessed that, although a landing back on the runway may have been possible, the aircraft was capable of climbing safely on one engine. However, when he determined that the aircraft was not climbing, and that the airspeed had reduced below 81 kts, the pilot in command took control, and at 09:09:38 advised the Tower that he was ditching the aircraft. He manoeuvred the aircraft as close as possible to the southern end of the partially constructed runway 16L. The aircraft was ditched approximately 46 seconds after the pilot in command first advised the Tower of the problem. The four crew and 21 passengers successfully evacuated the aircraft before it sank. They were taken on board pleasure craft and transferred to shore. The investigation found that the circumstances of the accident were consistent with the left engine having suffered a substantial power loss when an inlet valve stuck in the open position. The inability of the handling pilot (co-pilot) to obtain optimum asymmetric performance from the aircraft was the culminating factor in a combination of local and organisational factors that led to this accident. Contributing factors included the overweight condition of the aircraft, an engine overhaul or maintenance error, non-adherence to operating procedures and lack of skill of the handling pilot. Organisational factors relating to the company included: 1) inadequate communications between South Pacific Airmotive Pty Ltd who owned and operated the DC-3 and were based at Camden, NSW and the AOC holder, Groupair, who were based at Moorabbin, Vic.; 2) inadequate maintenance management; 3) poor operational procedures; and 4) inadequate training. Organisational factors relating to the regulator included: 1) inadequate communications between Civil Aviation Authority offices, and between the Civil Aviation Authority and Groupair/South Pacific Airmotive; 2) poor operational and airworthiness control procedures; 3) inadequate control and monitoring of South Pacific Airmotive; 4) inadequate regulation; and 5) poor training of staff.