Incident Overview

Description
Metro III VH-OZA was cleared for takeoff from runway 16R at the Sydney-Kingsford Smith Airport, NSW (SYD). It became airborne at 23:23 and shortly afterwards the pilot had been instructed to transfer to the departures controllers radio frequency. On first radio contact with that controller, the pilot was advised that the aircraft was identified on radar. At 23:25:30, the controller instructed the pilot to turn left onto a heading of 090 degrees, which was acknowledged. Instead of the expected left turn, the radar returns indicated that the aircraft was turning right, towards the south-west. At 23:25:54, the controller confirmed with the pilot that he was to turn left and at 23:25:59 the pilot once again acknowledged the left turn and added “Ive got a slight technical fault here”. No further transmissions were received from the pilot. The radar returns over the next 70 seconds showed the aircraft completed a left turn followed by a right turn before disappearing from radar. The Metro crashed into the sea. On 12 May 2008, a significant wreckage field was identified. That wreckage was spread over an area approximately 1,200 m long and 400 m wide. CONTRIBUTING SAFETY FACTORS: – It was very likely that the aircrafts alternating current electrical power system was not energised at any time during the flight. – It was very likely that the aircraft became airborne without a functioning primary attitude reference or autopilot that, combined with the added workload of managing the slight technical fault, led to pilot spatial disorientation and subsequent loss of control. OTHER SAFETY FACTORS: – The pilots Metro III endorsement training was not conducted in accordance with the operators approved training and checking manual, with the result that the pilots competence and ultimately, safety of the operation could not be assured. [Significant safety issue] – The chief pilot was performing the duties and responsibilities of several key positions in the operators organisational structure, increasing the risk of omissions in the operators training and checking requirements. – The conduct of the flight single-pilot increased the risk of errors of omission, such as not turning on or noticing the failure of aircraft items and systems, or complying with directions.
Primary Cause
Pilot spatial disorientation due to a combination of a technical fault, workload, and lack of proper training and checks.Pilot spatial disorientation due to a combination of a technical fault, workload, and lack of proper training and checks.Share on: