2000 Queensland Beechcraft King Air crash

Aviation accident in Australia August 2019 September 2011 VH-SKC B.King Air 200 Central Avn PER 29SEP99 (6788436514).jpg A small aircraft with two propeller engines and six cabin windows on the ground VH-SKC, the aircraft involved in the accident, seen in 1999 4 September 2000 Crew incapacitation due to uncontrolled decompression; cause unknown Accident 65 km south-east of Burketown, Queensland, Australia -18.125 140.05 type:landmark_region:AU-QLD 65 km south-east of Burketown inline,title Beechcraft 200 Super King Air SIERRA KILO CHARLIE VH-SKC Perth Airport, Perth, Western Australia Leonora Airport, Leonora, Western Australia 8 7 1 8 0 Central Air On 4 September 2000, a chartered Beechcraft 200 Super King Air departed Perth for a flight to the mining town of Leonora, Western Australia. The aircraft crashed near Burketown, Queensland, Australia, resulting in the deaths of all eight occupants.http://www.theage.com.au/articles/2002/03/23/1016843080716.html The lonely end to a fateful trip The Age Steve Pennells 24 March 2002 live https://web.archive.org/web/20141113024924/http://www.theage.com.au/articles/2002/03/23/1016843080716.html 13 November 2014 During the flight, the aircraft climbed above its assigned altitude. When air traffic control (ATC) contacted the pilot, the pilot's speech had become significantly impaired, and he was unable to respond to instructions. Three aircraft intercepted the Beechcraft, but were unable to make radio contact. The aircraft continued flying on a straight north-easterly heading for five hours, before exhausting its fuel and crashing 65 km south-east of Burketown."Plane Crashes in Australia, All Eight Aboard Dead", Peoples Daily, 5 September 2000. Retrieved 1 February 2012 https://web.archive.org/web/20080916091901/http://english.peopledaily.com.cn/english/200009/05/eng20000905_49748.html 16 September 2008 The crash became known in the media as the "ghost flight".Family of Ghost Flight plane crash victims angry with aviation regulator, CASA https://web.archive.org/web/20080129025055/http://www.abc.net.au/pm/content/2003/s860702.htm 29 January 2008 , ABC, 21 May 2003. Retrieved 1 February 2012No sound from pilot as ghost flight kept going https://web.archive.org/web/20120203112828/http://au.news.yahoo.com/thewest/a/-/news/9642425/no-sound-from-pilot-as-ghost-flight-kept-going/ 3 February 2012 , The West Australian, 15 June 2011. Retrieved 1 February 2012 A subsequent investigation by the Australian Transport Safety Bureau (ATSB) concluded that the pilot and passengers had become incapacitated and had been suffering from hypoxia, a lack of oxygen to the body, meaning the pilot would have been unable to operate the aircraft. Towards the end of the flight, the left engine stopped due to fuel exhaustion, and the aircraft crashed into the ground. The investigation report said that, due to extensive damage to the aircraft, investigators were unable to conclude if any of the eight aboard had used the oxygen system. The final report stated that the ATSB could not determine what incapacitated the occupants. A number of safety recommendations were made following the crash. Background The aircraft involved in the crash was a Beechcraft 200 Super King Air, registration VH-SKC, manufactured in 1975. The aircraft had about 19,000 hours of service before the crash.Australian Transport Safety Bureau 2001, p. 4. The amount of air passed into the cabin is controlled by bleed air valves on the engines. The positions of the bleed air valves can be altered by the pilot.Australian Transport Safety Bureau 2001, p. 7. According to the investigation report, "The aircraft was not fitted with a high cabin altitude aural warning device, nor was it required to be."Australian Transport Safety Bureau 2001, p. 6. The aircraft was fitted with an emergency oxygen system—an oxygen tank which could supply oxygen to the crew through two masks located in the cockpit, and to passengers through masks which drop from the ceiling of the cabin.Australian Transport Safety Bureau 2001, p. 8. Investigators concluded the aircraft was airworthy at the time of the crash, and a pilot who flew the aircraft earlier in the day said the aircraft functioned normally.Australian Transport Safety Bureau 2001, p. 12. The investigation report stated that "the maintenance release was current, and an examination of the aircraft's maintenance records found no recurring maintenance problems that may have been factors in the accident."Australian Transport Safety Bureau 2001, p. 11. Crash thumb|left|The aircraft was flying to Gwalia Gold Mine, in Leonora, Western Australia.|alt=A black and white photograph of a busy mine with several smoking chimneys and industrial buildings On Monday 4 September 2000,Australian Transport Safety Bureau 2001, p. 1. the Beechcraft, chartered by mining company Sons of Gwalia,Lalor Peter Media Release re: Aircraft Accident 4 January 2011 http://www.asx.com.au/asx/statistics/displayAnnouncement.do?display=text&issuerId=1167&announcementId=202941 Sons of Gwalia 5 January 2011 live https://web.archive.org/web/20110706102037/http://www.asx.com.au/asx/statistics/displayAnnouncement.do?display=text&issuerId=1167&announcementId=202941 6 July 2011 departed Perth, Western Australia, for the town of Leonora, Western Australia. On board were seven mine workers travelling to Gwalia Gold Mine. The aircraft took off from Perth at 6:09 pm local time (10:09 Coordinated Universal Time (UTC)), and was cleared by ATC to climb to FL130 (13000 ft m). Five minutes later, at 10:15, it was further cleared to its cruising altitude of FL250 (25000 ft m); and instructed to be at FL160 (16000 ft m) by 36 nmi from Perth. The pilot acknowledged this transmission. Five minutes later, at 10:20, as the aircraft climbed through FL156 (15600 ft m), it was cleared to waypoint DEBRA. The pilot again acknowledged. At approximately 10:33, the aircraft passed through its cleared level, and at FL256 (25600 ft m), ATC asked the pilot to confirm his altitude. "Sierra Kilo Charlie—um—standby," the pilot replied. This was the final spoken transmission from the aircraft, and its climb continued. According to the investigation report, several open-microphone transmissions followed, with the sound of background noise from the engines, a person breathing, "one unintelligible syllable," and "two chime-like tones, similar to those generated by electronic devices." During this time, ATC attempted to regain contact with the pilot. At 10:40, the controller called out, "Sierra Kilo Charlie Sierra Kilo Charlie, Melbourne Centre, if receiving this transmission squawk ident."Australian Transport Safety Bureau 2001, p. 36. At 10:41, the controller asked again, "Sierra Kilo Charlie, only receiving open mike from you. Would you contact me on one two five decimal two."Australian Transport Safety Bureau 2001, p. 37. thumb|The aircraft was sighted by the two aircraft in the Northern Territory, northwest of Alice Springs|alt=An expansive plain with a large mountainous ridge running through it along a curved line The aircraft continued to climb, and left radar coverage at 11:02, passing FL325 (32500 ft m). Thirty-one minutes later, Australian Search and Rescue asked the crew of a business jet to approach the Beechcraft. They reported that it was in level flight at FL343 (34300 ft m), and they could see no movement on the flight deck or in the cabin. However, the conditions made it difficult to observe closely. Two other aircraft which were asked to monitor the Beechcraft intercepted it over the Northern Territory, north-west of Alice Springs. The pilots reported that it was now in a steady descent, and both aircraft followed it as its airspeed increased. The investigation report stated that the pilots observed that "although its external lights were on, nothing could be seen inside the cabin." The investigation report then describes how "the crews of the chase aircraft attempted to contact the pilot of the Beechcraft by radio, but they did not receive a response." At 15:10, the aircraft turned left through 90 degrees as it descended through 5000 ft m. About 65 km south-east of Burketown, Queensland, it hit the ground and disintegrated.Australian 'ghost flight' still a mystery https://news.bbc.co.uk/2/hi/asia-pacific/2253039.stm 8 January 2011 BBC News Online 12 September 2002 live https://web.archive.org/web/20060223105348/http://news.bbc.co.uk/1/hi/world/asia-pacific/2253039.stm 23 February 2006 The pilot and seven passengers were killed.Australian Transport Safety Bureau 2001, p. 2. Investigation The crash was investigated by the Australian Transport Safety Bureau (ATSB), a federal body responsible for investigating transportation accidents in Australia.Australian Transport Safety Bureau 2001, p. v. The final report was published in March 2001.Australian Transport Safety Bureau 2001, p. ii. The report was unable to make a definitive conclusion as to the cause of the crash.Australian Transport Safety Bureau 2001, p. vii. The report found all those aboard the aircraft, including the pilot, had likely become incapacitated and begun suffering from hypoxia.Australian Transport Safety Bureau 2001, p. 26. The report stated, "After the aircraft climbed above the assigned altitude of FL250, the speech and breathing patterns of the pilot, evidenced during the radio transmissions, displayed changes consistent with hypoxia."Australian Transport Safety Bureau 2001, p. 29. Investigators were, however, unable to conclusively dismiss toxic fumes as the cause.Marks Kathy Inquest fails to solve mystery of 'ghost plane' that flew for six hours https://www.independent.co.uk/news/world/australasia/inquest-fails-to-solve-mystery-of-ghost-plane-that-flew-for-six-hours-642638.html 8 January 2010 The Independent 13 September 2002 live https://web.archive.org/web/20121110091522/http://www.independent.co.uk/news/world/australasia/inquest-fails-to-solve-mystery-of-ghost-plane-that-flew-for-six-hours-642638.html 10 November 2012 "The incapacitation of the pilot and passengers was probably due to hypobaric hypoxia because of the high cabin altitude and their not receiving supplemental oxygen" the report said, adding, "The reasons for the pilot and passengers not receiving supplemental oxygen [from the oxygen tank aboard the aircraft] could not be determined." The ATSB found it likely that the autopilot was engaged, and this caused the aircraft to fly on a straight heading; the vertical path of the aircraft indicated climb power had been set before the occupants of the aircraft were incapacitated. According to the report, "the design of the aircraft systems were such that, with the autopilot engaged, the engines would continue to operate, and the aircraft would continue to fly without human input until it was disrupted by other events, such as collision or fuel exhaustion." It was suggested that, towards the end of the flight, the fuel tank for the left engine was almost empty. "The near exhaustion of fuel in the left wing tanks may have produced at least one, and probably several, momentary losses of left engine power shortly before all power was lost," the report said. "The aircraft yawed and rolled towards the left engine, as was observed shortly before the aircraft collided with the ground."Australian Transport Safety Bureau 2001, p. 25. The report said due to the damage to the aircraft upon impact with the ground, investigators were unable to conclude if any of the eight aboard used the oxygen system. However, the report stated "The absence of a distress radio call, or an attempt to descend the aircraft, and the likelihood that the pilot did not don his oxygen mask, suggested that the pilot was unaware that the aircraft was unpressurised or depressurising." The passengers, the report added, were also likely not wearing their oxygen masks, as there was no noise recorded on the ATC transmissions indicating they were attempting to assist the pilot. Investigators were not able to determine what caused the depressurisation of the aircraft, but stated likely causes included either an incorrect switch selection due to pilot error, or a mechanical failure in the aircraft pressurisation system. The air traffic control recordings suggested it was unlikely that a rapid decompression had occurred. The report explains how "during an explosive or rapid depressurisation of a pressurised aircraft, however, the noise, pressure changes, temperature changes, and draughts within the cabin would have alerted the occupants that a substantial failure had occurred." The document listed the two main factors in the crash as: 1. The aircraft was probably unpressurised for a significant part of its climb and cruise for undetermined reasons. 2. The pilot and passengers were incapacitated, probably due to hypobaric hypoxia, because of the high cabin altitude and their not receiving supplemental oxygen. Aural warning In the aftermath of an incident in 1999 in which the pilot of a Beechcraft Super King Air suffered hypoxia, the ATSB published Report 199902928, and recommended an aural warning be fitted on the flight deck of all Australian Beechcraft Super King Air aircraft.Australian Transport Safety Bureau 2001, p. 27.Investigation No. 199902928 https://web.archive.org/web/20120122140812/http://atsb.gov.au/publications/investigation_reports/1999/AAIR/aair199902928.aspx 22 January 2012 Australian Transport Safety Bureau, 7 February 2001. Retrieved 1 February 2012Australian Transport Safety Bureau 2001, Section 1.17, p. 20. The flight deck of the Beechcraft Super King Air only has visual warning of inadequate cabin pressure.Australian Transport Safety Bureau 2001, Section 1.6.3.1, p. 5. In the aftermath of the Ghost Flight, the Civil Aviation Safety Authority issued a Discussion PaperDiscussion Paper DP 0102 CS – Proposal for Aural Warning to Operate With Cabin Altitude Alert Warning Systems https://web.archive.org/web/20080805164310/http://casa.gov.au/newrules/parts/039/download/dp0102cs.pdf 5 August 2008 , CASA, February 2001. Retrieved on 1 February 2012 and a Notice of Proposed Rule Making (NPRM),Notice of Proposed Rule Making 0216 CS – Proposal for Aural Warning to Operate With Cabin Altitude Warning Systems https://web.archive.org/web/20080805152004/http://casa.gov.au/newrules/parts/039/download/nprm0216cs.pdf 5 August 2008 , CASA, April 2002. Retrieved on 1 February 2012 both proposing aural warning in the Beechcraft Super King Air and other pressurised aircraft. The outcome of consultation on the NPRM was that the Civil Aviation Safety Authority did not mandate aural warning of inadequate cabin pressure, and this angered the families of some of the victims. Instead, the Civil Aviation Safety Authority issued a notice to owners of pressurised aircraft registered in Australia and recommended installation of an aural warning, but did not make it mandatory. The notice said: "The benefit to your pilots and passengers lies in the reduction in risk of an uncommanded depressurisation leading to an incident or fatal accident. The benefit is much greater than the cost of purchase and installation of one of these low-cost systems."Aviation safety recommendations and advisory notices http://www.atsb.gov.au/publications/recommendations/2000/r20000288.aspx Australian Transport Safety Bureau 8 January 2010 live https://web.archive.org/web/20101212161417/http://atsb.gov.au/publications/recommendations/2000/r20000288.aspx 12 December 2010 Coroner's inquest thumb|alt=Memorial at Gwalia to the victims of the crash|Memorial at Gwalia to the victims of the crash The West Australian Coroner, Mr. Alistair Hope, conducted an inquest into the deaths of the eight occupants of the aircraft. The inquest determined that the deaths were accidental, but was unable to determine the cause of the crash. The Coroner recommended an aural alarm system for pressurised aircraft, and a low-cost flight data recorder.Ian Townsend, "Coroner criticises ATSB following plane crash", ABC-PM, 12 September 2002. Retrieved 1 February 2012 https://web.archive.org/web/20080208143632/http://www.abc.net.au/pm/stories/s674866.htm 8 February 2008 The Coroner was critical of the poor co-ordination between the ATSB, the Queensland Police, and the Civil Aviation Safety Authority (CASA). He also criticised the ATSB for failing to take notes when interviewing witnesses, and for its poor presentation of evidence. Air traffic control When the air traffic controller responsible for the Beechcraft received the open-microphone transmissions, he alerted his supervisor that he was concerned the pilot could be suffering from hypoxia. The controller and his supervisor completed the standard checklist which, at the time, did not include a procedure to follow in the case of incapacitation or hypoxia. In the aftermath of the crash, the checklist was changed to "incorporate procedures to be followed by air traffic controllers, when a controller suspects that a pilot has been affected by hypoxia."Australian Transport Safety Bureau 2001, p. 13. See also Aviation Australia 1999 South Dakota Learjet crash 2000 in aviation 2000 in Australia Helios Airways Flight 522 2022 Baltic Sea Cessna crash Notable decompression accidents and incidents References Notes 30em Further reading Pilot and Passenger Incapacitation (Investigation Report 200003771) Australian Transport Safety Bureau 0-642-20046-7 50 Australia https://www.atsb.gov.au/media/24344/aair200003771_001.pdf March 2001 8 January 2011 10 January 2022 https://web.archive.org/web/20220110143114/https://www.atsb.gov.au/media/24344/aair200003771_001.pdf dead Category:Aviation accidents and incidents in 2000 Category:Aviation accidents and incidents in Queensland Category:Airliner accidents and incidents caused by pilot incapacitation Category:Aviation accidents and incidents involving the Beechcraft Super King Air Category:Decompression accidents and incidents Category:Disasters in Queensland Category:North West Queensland Category:2000s in Queensland Category:September 2000 in Australia Category:2000 disasters in Australia