Sydney - Goulburn

Prior to departure the pilot had received a weather forecast which indicated that fog could be expected at the destination. Adequate fuel was carried in the aircraft tanks to allow for a considerable period of holding and/or a diversion to another aerodrome if required. After an apparently normal flight of 35 minutes the aircraft arrived in the Goulburn area and the pilot reported his intention to carry out a standard instrument approach. The manoeuvres associated with this procedure do not involve flight over the city of Goulburn, however witnesses observed the aircraft as it circled over the city several times at a relatively low height. It was then seen to roll and descend steeply before striking two houses. A fierce fire broke out which engulfed the aircraft and both residences. The three persons on board the aircraft and a person in one of the houses received fatal injuries. A detailed inspection of the wreckage revealed that the camshaft of the left engine had failed in flight and the pilot had apparently feathered the propeller. The engine was not operating at the time of impact. No other defect or malfunction was discovered which might have contributed to the development of the accident. It was determined that the particular camshaft had failed from fatigue cracking, resulting from defective manufacture. It was considered likely that when the aircraft arrived over Goulburn, shallow fog obscured all or part of the aerodrome. The lights of the city would have been clearly visible and the pilot probably decided to use the city, rather than the nearby radio navigation aid, as a convenient holding point while waiting for conditions at the aerodrome to improve. During a series of left hand orbits, and after advising his intention to conduct an instrument approach, the pilot experienced a complete failure of the left engine. In order to realise the available single-engine performance of the aircraft the pilot had to perform a series of checks and actions which would result in the applicable propeller being feathered; any unnecessary aerodynamic drag being reduced; and an appropriate airspeed being established. It was determined that although the propeller had probably been feathered, the landing gear, which had evidently been lowered previously, had not been raised to reduce drag. In addition, an analysis of radar returns from the aircraft, recorded at Canberra, indicated that the airspeed at which the aircraft was flying shortly before radar contact was lost, was less than the optimum figure. The final manoeuvre described by witnesses was consistent with that which follows a loss of control in twin engine aircraft when power is being supplied by only one engine and the speed is below the minimum required for full control. The reason the pilot did not raise the landing gear and maintain the required minimum control speed could not be established.

Flight / Schedule

Sydney - Goulburn

Aircraft

Cessna 340

Registration

VH-BYB

MSN

340A-0411

Year of Manufacture

1978

Date

May 16, 1984 at 11:04 PM

Type

CRASH

Flight Type

Private

Flight Phase

Landing (descent or approach)

Crash Site

City

Crash Location

Goulburn New South Wales

Region

Oceania • Australia

Coordinates

-34.7604°, 149.7120°

Crash Cause

Technical failure

Narrative Report

On May 16, 1984 at 11:04 PM, Sydney - Goulburn experienced a crash involving Cessna 340, operated by Private Australian, with the event recorded near Goulburn New South Wales.

The flight was categorized as private and the reported phase was landing (descent or approach) at a city crash site.

3 people were known to be on board, 4 fatalities were recorded, 0 survivors were identified or estimated. This corresponds to an estimated fatality rate of 133.3%.

Crew on board: 1, crew fatalities: 1, passengers on board: 2, passenger fatalities: 2, other fatalities: 1.

The listed crash cause is technical failure. Prior to departure the pilot had received a weather forecast which indicated that fog could be expected at the destination. Adequate fuel was carried in the aircraft tanks to allow for a considerable period of holding and/or a diversion to another aerodrome if required. After an apparently normal flight of 35 minutes the aircraft arrived in the Goulburn area and the pilot reported his intention to carry out a standard instrument approach. The manoeuvres associated with this procedure do not involve flight over the city of Goulburn, however witnesses observed the aircraft as it circled over the city several times at a relatively low height. It was then seen to roll and descend steeply before striking two houses. A fierce fire broke out which engulfed the aircraft and both residences. The three persons on board the aircraft and a person in one of the houses received fatal injuries. A detailed inspection of the wreckage revealed that the camshaft of the left engine had failed in flight and the pilot had apparently feathered the propeller. The engine was not operating at the time of impact. No other defect or malfunction was discovered which might have contributed to the development of the accident. It was determined that the particular camshaft had failed from fatigue cracking, resulting from defective manufacture. It was considered likely that when the aircraft arrived over Goulburn, shallow fog obscured all or part of the aerodrome. The lights of the city would have been clearly visible and the pilot probably decided to use the city, rather than the nearby radio navigation aid, as a convenient holding point while waiting for conditions at the aerodrome to improve. During a series of left hand orbits, and after advising his intention to conduct an instrument approach, the pilot experienced a complete failure of the left engine. In order to realise the available single-engine performance of the aircraft the pilot had to perform a series of checks and actions which would result in the applicable propeller being feathered; any unnecessary aerodynamic drag being reduced; and an appropriate airspeed being established. It was determined that although the propeller had probably been feathered, the landing gear, which had evidently been lowered previously, had not been raised to reduce drag. In addition, an analysis of radar returns from the aircraft, recorded at Canberra, indicated that the airspeed at which the aircraft was flying shortly before radar contact was lost, was less than the optimum figure. The final manoeuvre described by witnesses was consistent with that which follows a loss of control in twin engine aircraft when power is being supplied by only one engine and the speed is below the minimum required for full control. The reason the pilot did not raise the landing gear and maintain the required minimum control speed could not be established.

Aircraft reference details include registration VH-BYB, MSN 340A-0411, year of manufacture 1978.

Geospatial coordinates for this crash are approximately -34.7604°, 149.7120°.

Fatalities

Total

4

Crew

1

Passengers

2

Other

1

Crash Summary

Prior to departure the pilot had received a weather forecast which indicated that fog could be expected at the destination. Adequate fuel was carried in the aircraft tanks to allow for a considerable period of holding and/or a diversion to another aerodrome if required. After an apparently normal flight of 35 minutes the aircraft arrived in the Goulburn area and the pilot reported his intention to carry out a standard instrument approach. The manoeuvres associated with this procedure do not involve flight over the city of Goulburn, however witnesses observed the aircraft as it circled over the city several times at a relatively low height. It was then seen to roll and descend steeply before striking two houses. A fierce fire broke out which engulfed the aircraft and both residences. The three persons on board the aircraft and a person in one of the houses received fatal injuries. A detailed inspection of the wreckage revealed that the camshaft of the left engine had failed in flight and the pilot had apparently feathered the propeller. The engine was not operating at the time of impact. No other defect or malfunction was discovered which might have contributed to the development of the accident. It was determined that the particular camshaft had failed from fatigue cracking, resulting from defective manufacture. It was considered likely that when the aircraft arrived over Goulburn, shallow fog obscured all or part of the aerodrome. The lights of the city would have been clearly visible and the pilot probably decided to use the city, rather than the nearby radio navigation aid, as a convenient holding point while waiting for conditions at the aerodrome to improve. During a series of left hand orbits, and after advising his intention to conduct an instrument approach, the pilot experienced a complete failure of the left engine. In order to realise the available single-engine performance of the aircraft the pilot had to perform a series of checks and actions which would result in the applicable propeller being feathered; any unnecessary aerodynamic drag being reduced; and an appropriate airspeed being established. It was determined that although the propeller had probably been feathered, the landing gear, which had evidently been lowered previously, had not been raised to reduce drag. In addition, an analysis of radar returns from the aircraft, recorded at Canberra, indicated that the airspeed at which the aircraft was flying shortly before radar contact was lost, was less than the optimum figure. The final manoeuvre described by witnesses was consistent with that which follows a loss of control in twin engine aircraft when power is being supplied by only one engine and the speed is below the minimum required for full control. The reason the pilot did not raise the landing gear and maintain the required minimum control speed could not be established.

Cause: Technical failure

Occupants & Outcome

Crew On Board

1

Passengers On Board

2

Estimated Survivors

0

Fatality Rate

133.3%

Known people on board: 3

Operational Details

Schedule / Flight

Sydney - Goulburn

Flight Type

Private

Flight Phase

Landing (descent or approach)

Crash Site

City

Region / Country

Oceania • Australia

Aircraft Details

Aircraft

Cessna 340

Registration

VH-BYB

MSN

340A-0411

Year of Manufacture

1978

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