AIRCRAFT ACCIDENT INVESTIGATION

Report 852-1056

Israel Aircraft Industries

1124 West wind
VH-IWJ
Near Sydney, New South Wales
10 October 1985

BUREAU OF AIR SAFETY INVESTIGATION

AIRCRAFT ACCIDENT INVESTIGATION
REPORT 852-1056

PEL-AIR AVIATION PTY LTD

ISRAEL AIRCRAFT INDUSTRIES 1124 WESTWIND
VH-IWJ
NEAR SYDNEY, NEW SOUTH WALES
10 OCTOBER 1985

The Secretary to the Department of Aviation authorised the investigation of

this accident and the publication of this report pursuant to the poaers
conferred by Air Navigation Regulations 278 and 283 respectively.

Prepared by the Bureau of Air Safety Investigation

October 1986

A U S T R A L I A N GOVERNMENT PUBLISHING S E R V I C E
CANBERRA 1986
© Commonwealth of Australia 1986
I S B N 064<4055'*5

Printed in Australia by Better Printing Service, 44 Paterson Parade, Queanbeyan, N.S.W.

CONTENTS

Synopsl s 1
1. Factual Information
1.1 History of the flight 1
1.2 Injuries to persons 3
1.3 Damage to aircraft 3
1.4 Other damage 3
1.5 Personnel 1 nf ormatl on 3
1.6 Aircraft Information
1.6.1 History 4
1.6.2 Loading 4
1.6.3 Fuel considerations 4
1.6.4 Maintenance and serviceability 5
1.6.4.1 Attitude Instruments required for flight 6
1.6.4.2 Instrument unservlceablHty 6
1.7 Meteorologlcal Information 8
1.8 Aids to navigation 8
1.9 Communications 8
1.10 Aerodrome Information 9
1.11 Flight recorders
1.11.1 Cockpit Voice Recorder 9
1.11.2 Flight Data Recorder 10
1.12 Wreckage and Impact Information 11
1.12.1 Search and recovery 11
1.13 Medical and pathological Information
1.13.1 Medical reports 13
1.13.2 Pathology 13
1.14 Fire 13
1.15 Survival aspects 13
1.16 Tests and research
1.16.1 The crew
1.16.1.1 The pilot 1n command 14
1.16.1.2 The co-pilot 14
1.16.2 The aircraft
1.16.2.1 Structure 15
1.16.2.2 Engines 15
1.16.2.3 Control surfaces 16
1.16.2.4 Stabiliser trim 16
1.16.3 Other research
1.16.3.1 Blrdstrlke 16
1.17 Additional Information
1.17.1 Criminal allegations 16
1.17.2 Recorded radar information 17
 1.18 New Investigation techniques
1.18.1 Use of hypnosis 17
1.18.2 Pilot performance experiments 1n flight simulator..18
2 Analysis
2.1 General 19
2.2 The aircraft 19
2.3 The crew 20
2.4 Meteorological conditions 20
2.5 The accident sequence 20
2.5.1 Structural failure of the alrframe 21
2.5.2 Uncommanded elevator trim Inputs 21
2.5.3 Sabotage . 21
2.5.4 Collision with another aircraft or object 22
2.5.5 Pilot 1ncapac1tat1on 22
2.5.6 Suicide 22
2.6 Spatlal dlsorlentatlon 22
2.6.1 Simulation of flight Instrument unserv1ceabH1ty...23
3 Concl uslons 23
4 Relevant events and factors 25
5 Safety recommendations 25
Appendix
A Standard Instrument Departure chart 26
B Flight Data Recorder presentation 27
C Transcript of Cockpit Voice Recorder Information...28
Note : All times shown are Australian Eastern Standard Time
(Greenwich Mean Time plus 10 hours), and are based
on the 24-hour clock:
 THE ACCIDENT

At approximately 0059 hours Eastern Standard Time (EST) on 10 October 1985

Israel Aircraft Industries (IAI) 1124 Westwlnd aircraft, registered
VH-IWJ, crashed Into the sea off the South Head of Botany Bay, New South
Wales (NSW). The wreckage came to rest In 92 metres of water.
VH-IWJ was engaged 1n operating a cargo flight with a crew of two pilots
and carrying no passengers. Both members of the flight crew received
fatal Injuries and the aircraft was destroyed.

1. FACTUAL INFORMATION
1.1 HISTORY OF THE FLIGHT
IAI 1124 Westwlnd aircraft, registered VH-IWJ, was operating under a
current Certificate of Registration, the holder of which was Pel-Air
Aviation Pty Ltd (Pe1-A1r). The aircraft was operated by Pel-A1r and, at
the time of the accident, 1t was engaged on a regularly scheduled cargo
service. This service was operated under the terms of a current Charter
and Aerial Work Licence, and was flown on behalf of Ansett Air Freight, a
subsidiary of Ansett Transport Industries Pty Ltd. The particular flight,
designated Flight 474, was operated on 4 nights each week from Sydney to
Brisbane and Cairns, Queensland.
The aircraft had departed Cairns earlier In the evening and had flown via
Brisbane to Sydney, arriving at 2336 hours. The arriving crew reported
that the aircraft was performing normally. A total of 1350 litres of fuel
was added to the aircraft tanks and loading of general cargo was carried
out by Ansett A1r Freight personnel.
The flight plan submitted to Air Traffic Control (ATC) Indicated that the
flight would follow the normal Instrument Flight Rules (IFR) procedures.
The estimated time Interval to Brisbane was 70 minutes at planned Flight
Level 370 (approximate altitude of 37000 feet). The aircraft carried
sufficient fuel for 164 minutes of flight, and refuelling was planned to
take place at Brisbane prior to departure for Cairns.
Pel-Air Intended to use the flight to assess the performance of the
rostered co-p1lot, who was being considered for upgrading to command
status. He was to occupy the left hand control seat, while the right hand
seat occupant was the Chief Pilot of the company.
At 0033 hours the crew established radio contact on the Sydney ATC
Clearance Delivery frequency, and were given a "16 West Maitland One"
Standard Instrument Departure (SID). The flight pattern associated with
this clearance requires the aircraft to maintain heading after take-off on
Runway 16 until reaching a height of 500 feet, when a left turn is made to
intercept the 126 radial of the Sydney VOR (Very High Frequency
Omni-directional Range). At a position of 6 nautical miles by
Distance Measuring Equipment (DME) from the aerodrome, a left turn onto
357 degrees is made 1n order to continue tracking with reference to the
West Haiti and VOR. A copy of the applicable SID chart is shown at
Appendix A.
Shortly before 0049 hours the crew contacted Sydney Control Tower, and the
aircraft was directed to taxy for a departure from Runway 16. At the time
the wind was light and variable. After receiving the appropriate
clearance, an evidently normal take-off was made, and at 0056 hours
contact was established with Sydney Departures Control. The pilot in
command advised that the aircraft was on climb to Flight Level 370 , and
requested the direct track to Brisbane. This was a standard request, to
allow the aircraft to proceed directly to the destination rather than
follow the various radio navigation aids along the route. Such a request
was normally granted by ATC if the general traffic situation permitted use
of the direct track, and provided the aircraft was equipped with a
suitable navigation system. VH-IWJ was fitted with a VLF/Omega navigation
system which was capable of direct tracking. After ascertaining this, the
Departures controller advised the aircraft that the direct track to
Brisbane would probably be available. The acknowledgment of this comment
was the last recorded transmission from the aircraft.
Shortly before 0059 hours the Departures controller broadcast the
clearance for the aircraft to track direct to Brisbane at the planned
cruising level. No response was received from the aircraft, although the
controller noted that radar returns were still visible on his screen.
Shortly afterwards, these returns faded, and the Distress Phase of Search
and Rescue procedures was Instituted at 0100 hours.
At about this time, a number of persons observed what appeared to be the
lights of an aircraft descending rapidly towards the sea. The lights
maintained their position relative to each other, indicating that the
aircraft was not rotating as It descended.
The aircraft had faded from the radar screen at a point about 11
kilometres south-east of Sydney Airport. A search of the area was
commenced using helicopters and boats. Wreckage Identified as being from
the aircraft was sighted by a helicopter at 0245 hours. Recovery of
pieces of the aircraft structure, freight and human remains was effected
by Police and Department of Aviation launches. The degree of destruction
indicated that the aircraft had struck the water while travelling at high
speed.
The bulk of the wreckage was presumed to be lying in about 85 metres of
water about 5 kilometres out to sea from Botany Bay. An Intensive search
was carried out by vessels from the Royal Australian Navy, later assisted
by a vessel from the NSW Department of Fisheries and Agriculture. Use was
made of various underwater detection devices. Search efforts were
hampered by persistent unfavourable sea conditions and no trace was found
of the wreckage. Operations were finally suspended towards the end of
November 1985. An Internationally recognised underwater location and
salvage expert was then employed, and the wreckage was ultimately located
and identified In 92 metres of water on 20 January 1986. Recovery of the
Flight Data and Cockpit Voice Recorders, the major portions of both
engines, and sundry other pieces of the aircraft structure, was effected
the following month.

1.2 INJURIES TO PERSONS

Injuries Crew Passengers Others
Fatal 2
Serious - -
Minor/None
Total 2

1.3 DAMAGE TO AIRCRAFT

The aircraft was destroyed.

1.4 OTHER DAMAGE

No other property was damaged during the accident sequence.

1.5 PERSONNEL INFORMATION

The pilot In command of the aircraft, David Ian HASKETT, age 40 years, was
the Chief Pilot and the Chief Check and Training Pilot for Pel-Air. He
was the holder of a Senior Commercial Pilot Licence which was current to
28 February 1986. This licence was appropriately endorsed to permit him
to operate as pilot in command of the IAI Westwlnd type. He was also the
holder of a First Class Instrument Rating, endorsed for appropriate
navigation aids, which permitted him to operate aircraft under IFR
procedures. Mr Haskett's total flying experience at the time of the
accident was 9881 hours, of which 3101 hours had been gained 1n the
Westwlnd type. 2973 hours of these had been accumulated while acting as
pilot in command of the type. His most recent proficiency check had been
successfully completed on 21 May 1985 and his most recent pilot's medical
examination had been completed on 28 August 1985. In the 90 days
preceding the accident he had flown a total of 195 hours, all on the
Westwlnd type. In the 7 days preceding the accident he had flown 16 hours
15 minutes on 4 separate flights. 157 of the hours 1n the 90 day period
had been flown at night, and the accident flight was to be his third
consecutive night of duty. He had been off duty since 0930 hours on 9
October and did not return to duty until approximately 0020 hours oh 10
October.
The co-pilot of the aircraft was Edward Owen JACKSON, age 37 years. He
was the holder of a current Senior Commercial Pilot Licence, which was
valid to 30 November 1985. This licence was appropriately endorsed to
permit him to act as a co-p11ot on the Westwlnd type. He also held a
Second Class Instrument Rating, endorsed for appropriate navigation aids,
which permitted him to operate under IFR procedures. At the time of the
accident he had accumulated 8091 hours flying experience, of which 500 had
been gained as a co-pilot on Westwlnd aircraft. His most recent
proficiency check had been completed on 3 October 1985, and his most
recent aircrew medical examination had been conducted on 29 May 1985. In
the 90 days preceding the accident he had flown 190 hours, all on Westwlnd
aircraft, 154 of these were flown at night. In the preceding 7 days he
had flown 19 hours 50 minutes during 3 flights. He had been off duty
since completing a return flight from Darwin In the early hours of 9
October 1985.
A vacancy existed within Pel-A1r for a pilot In command for Westwlnd
aircraft. Mr Jackson had Indicated his desire for this position, and had
undergone an appraisal flight on 2 and 3 October 1985. The flight had
been under the command of Mr Haskett, who subsequently advised the company
management that Mr Jackson had not performed to a satisfactory standard.
Mr Jackson had been counselled on his performance, and had then spent a
considerable amount of time studying the appropriate books and manuals, 1n
preparation for a further appraisal on the flight on which the accident
occurred.

1.6 AIRCRAFT INFORMATION

1.6.1 History
VH-IWJ was an IAI 1124 Westwlnd aircraft, the construction of which had
been completed early 1n 1982 by Israel Aircraft Industries. It had been
allotted the manufacturer's serial number 371. The aircraft was purchased
by the original owner, Resources Jet Charter, and was flown to Australia
In April 1982. It had then been operated by a number of charter companies
until Peldale Pty Ltd acquired It 1n November 1984. In February 1985
Pel dale Pty Ltd became Pel-Air Aviation Pty Ltd. This company continued
to hold the aircraft Certificate of Registration, and operated and
maintained the aircraft. At the time of the accident It had flown a total
of 3105 hours since new.
1.6.2 Loading
The maximum permissible gross weight for take-off for the aircraft, having
regard to structural limitations, was 10660 kilograms (kg). Runway 16 at
Sydney Airport was sufficiently long for the aircraft to be able to
operate at this weight. The actual weight of the aircraft at take-off was
calculated to have been 8234 kg, Including 1047 kg of cargo. Much of the
cargo was of a bulky nature, and the freight carrying capacity of the
aircraft was limited by volumetric, rather than weight, considerations.
The centre of gravity of the aircraft was within the specified limits and
there was adequate fuel on board for the proposed flight.
1.6.3 Fuel Considerations
The total fuel capacity of the aircraft was 3959 kg. At the time the
aircraft landed at Sydney Airport there was approximately 509 kg of fuel
remaining 1n the tanks. Under Instructions from Mr Haskett, 1100 litres
(870 kg) of aviation turbine (Avtur) fuel was added by the BP company
refueller. The crew then became aware from the Briefing Office that the
weather at Brisbane was expected to deteriorate shortly after the planned
arrival time. Although there was no requirement for extra fuel to be
carried, the pilot In command elected to uplift a further 250 litres (198)
kg, making the total fuel load 1577 kg.
The tanker used to dispense the fuel into VH-IWJ had been checked for
water contamination earlier in the day. None had been found, and four
other aircraft had been refuelled prior to the initial 1100 litres
supplied to VH-IWJ. The tanker had subsequently been replenished from
depot stocks and again found free of water contamination. Another
aircraft had then been refuelled from the tanker prior to the final 250
litres added to VH-IWJ.
Immediately following notification of the accident, the fuel batch was
quarantined. Preliminary, and subsequently extensive, quality control
checks confirmed that the fuel as supplied was uncontamlnated and met the
appropriate product specifications.
1.6.4 Maintenance and Serviceability.
There was a current Certificate of Airworthiness for the aircraft, and
required maintenance had been carried out 1n accordance with a system
which had been approved by the then Department of Transport in 1979.
The system called up various items for maintenance and servicing each 150
hours of flight time, plus additional checks which were required every 75
hours.
A number of documents were used to record and control maintenance
activity. These were as follows:
(a) Scheduled Maintenance and Rectification Sheets (SMRS). These forms
are used to call up the maintenance required at a check inspection and to
record and certify the action taken. They are also used to record defects
found during the maintenance, and corrective action taken.
(b) Component History (CH), and Overhaul and Special Inspection Period
(OSIP) cards. The CH cards record the movement and time in service of
interchangeable components, while the OSIP cards specify the maintenance
required on interchangeable components and record maintenance carried out
on these Items.
(c) Aircraft Maintenance Log. This Is a booklet containing numbered
coupons, which are used to record defects occurring between scheduled
inspections and any rectification action taken.
(d) Deferred Log. This is a booklet, carried In the aircraft, which
contains details of any entries in the Aircraft Maintenance Log on whict
action has been deferred.
(e) Permissible Unserviceability Schedule. This document forms part of
the company operations manual for the aircraft type. It contains a
listing of the various components which are not considered to be critical
for normal flight operations, and may be temporarily unserviceable. The
schedule is approved by the Department of Aviation, and may be varied on
application by the operator.
The aircraft had flown a total of 59.5 hours in service since the last
scheduled maintenance Inspection, which had been completed on 26 September
1985. Two reported defects had not been rectified during this Inspection,
and entries 1n the Aircraft Maintenance Log Indicated that the details had
been transferred to a SMRS. One concerned spurious warnings being given
by the altitude alerting system, and a note on the SMRS Indicated that
spare parts were awaited for this equipment. This particular defect was
not considered to be relevant to the circumstances of the accident. The
other defect concerned the rate of turn Indicator fitted to the Flight
Attitude Director Indicator on the left Instrument panel. The rate of
turn Indicator was known to be operating in the reverse sense i.e., with
the aircraft turning to the left the indicator showed that a right turn
was taking place, and vice versa. This defect is discussed at paragraph
1.6.4.2.
1.6.4.1 Attitude Instruments Required for Flight
The cockpit configuration of VH-IWJ provided 3 separate flight attitude
indicators. These were:
a) the pilot's Flight Attitude Director Indicator, which incorporates a
flight director facility and provides flight attitude, as well as other
information to the pilot. The attitude signals are provided by the flight
guidance computer which 1s powered by the No.l AC Bus at 115 volts
alternating current (115Vac). A full-scale diagrammatic illustration of
this instrument Is shown at Figure 1.
b) the co-pilot's flight attitude Indicator which Is a self contained
Instrument and is powered by the No.2 Instrument Bus at 26Vac.
c) the emergency attitude indicator which is also self contained and is
powered from the No.2 Communications and Accessories Bus at 28 volts
direct current (28Vdc). This Instrument is located on the left instrument
panel. It Is also fitted with an emergency battery which will power it
for 30 minutes after any interruption to its principal power supply.
To avoid confusion, these three attitude Instruments will be referred to
throughout this report as Flight Attitude Indicators (FAI).
1.6.4.2 Instrument Unservlceability.
Under the terms of the relevant Air Navigation Orders, as the aircraft was
fitted with three independently powered attitude Indicators, there was no
requirement for it to be equipped with a rate of turn indicator. However,
as the Indicator was fitted, and was not Included in the aircraft
Permissible Unservlceability Schedule, it was required to be operating
correctly prior to take-off.
The rate of turn Indicator, which formed part of the pilot's FAI, had
first been reported as operating in the reverse sense on 23 October 1984.
This report had been entered In the aircraft maintenance log by Mr
HaskettT At that time the aircraft was being operated by Wings
Australia Pty Ltd and had accumulated 1487 hours time in
service since new. Maintenance personnel had been unable to isolate and
rectify the fault, which was reported 1n the log on three further
occasions.
 PITCH ATTITUDE ROLL ATTITUDE ROLL ATTITUDE DECISION HEIGHT
TAPE 300 200 10° ZERO INDEX POINTER ANNUNCIATOR

450

600
REFERENCE
COMMAND
BAR
BAR

GLIDESLOPE
FLAG
SPEED
FLAG

GLIDESLOPE SPEED
DEVIATION DEVIATION
POINTER POINTER

HORIZON
LINE
FLIGHT
DIRECTOR
ATTITUDE FLAG
FLAG
RUNWAY
SYMBOL
SYMBOLIC/
AIRCRAFT

ATTITUDE
SELF TEST RUNWAY
SWITCH FLAG
\
RATE OF TURN INCLINOMETER
FLAG

RATE OF TURN
POINTER

FIGURE 1
The rate of turn system has three main components. These are:
(a) a sensor, which Is a gyro that senses the direction and rate of turn
of the aircraft and converts this Information Into electric current for
transmission to the rate of turn Indicator. This sensor 1s mounted
beneath the cabin floor.
(b) a rate of turn Indicator, which 1s a simple ammeter calibrated to
Indicate the degree and direction of turn of the aircraft. It achieves
this by responding to the electric current originating from the sensor
referred to above. It 1s mounted on the lower casing of the pilot's
FAI.
(c) the Interconnecting wiring between the sensor and the Indicator.
After the first report of the unservlceablHty of the system the relevant
engineering staff carried out a number of checks and component changes to
rectify the fault. Three different Indicators and two different sensors
were fitted to the aircraft at different times during the period of the
reports. All of these units when fitted to other aircraft operated
correctly, but when fitted to VH-IWJ the rate of turn Indicator operated
1n the reverse sense. The engineering staff reported that they had
carried out continuity checks on the wiring between the two components and
those checks had confirmed that the aircraft was wired 1n accordance with
the aircraft wiring diagrams. Nevertheless, 1t was considered likely that
a fault had existed 1n the aircraft wiring, but the Investigation was
unable to determine the precise circumstances under which such a fault
might have occurred.

1.7 METEOROLOGICAL INFORMATION

At 0100 hours a meteorological observation was taken at Sydney Airport.
This recorded the surface wind as 158 degrees magnetic at 2 knots,
visibility 30 km, cloud one octa (eighth) of strato-cumulus at 5000 feet,
temperature 17 degrees Celsius (C) and QNH (altimeter sub-scale setting)
1020 millibars (mb). The Pilot Balloon flights from Sydney Airport
conducted 4 hours prior to, and 2 hours after the accident recorded
nothing that was considered of causal significance. On that morning, the
moon did not rise until 0315 hours.
Recorded weather Information was available via the Automatic Terminal
Information Service (ATIS). The Information current as the aircraft was
prepared for departure was coded Alpha, and advised that the wind was
light and variable, with a downwind component of 2 knots on runway 34.
The QNH was 1019 mb, temperature was 16 degrees C, and there was one octa
of cloud at 2500 feet.
1.8 AIDS TO NAVIGATION
All of the departure aerodrome and relevant en-route navigation aids were
serviceable at the time of the accident.
1.9 COMMUNICATIONS
All the required transmissions to and from the aircraft were made on the
correct frequencies. Neither the flight crew nor ATC reported any
difficulty with corranunlcations until the aircraft failed to reply to the
ATC Instruction to track direct to Brisbane.
1.10 AERODROME INFORMATION
Sydney (K1ngsford-Sm1th) Airport 1s located on the Northern shore of
Botany Bay and has two Intersecting runways. Runway 16 was 1n use for
departing aircraft at the time. This Is the preferred runway for night
operations, 1n order to minimise the effects of aircraft noise on suburbs
adjacent to the airport. The runway has dimensions of 3962 x 45 metres
and extends Into the Bay for some 2000 metres. It Is aligned In a
direction of 156 degrees magnetic.
The Sydney Control Tower 1s located to the south-west of the runway
Intersection and affords an unobstructed view of the the runways and
taxlways to the tower controllers. The Surface Movement Controller and
Aerodrome Controller are located In the Tower. The Departures Controller
who monitors the path of aircraft, primarily by radar, 1s located In the
Area Approach Control Centre (AACC) at the base of the Tower. The returns
received by the radar antennae heads are processed and transmitted to the
screens In the AACC. These radar antennae, for the Terminal Area and
Route Surveillance Radars, are located East of the runway Intersection.
The Senior Area Approach Controller confirmed the serviceability of the
radar equipment with the technicians on duty at the time of the accident.
1.11 FLIGHT RECORDERS
1.11.1 Cockpit Voice Recorder
The aircraft was equipped with a Fa1rch1ld A100 Cockpit Voice Recorder
(CVR) of conventional configuration applicable when the aircraft was first
registered 1n Australia. The CVR system 1s an audio recording system
which uses magnetic tape to retain the last thirty minutes of Information.
The tape 1s a continuous loop whereby previous Information Is
progressively erased as new recording takes place. Recording 1s commenced
when power 1s selected on to the No.2 AC Bus and the Avionics Master
Switch 1s on. The CVR system fitted to VH-IWJ allowed for the recording
of radio and cockpit Intercom transmissions. A separate track on the tape
was used to record the sounds detected by a remote cockpit area microphone
(CAM). The CAM was situated on the CVR control panel, which was 1n the
centre console between the two crew seats. This CAM track was the source
of all recorded conversation between the pilots and the various background
noises heard during the flight.
The CVR was recovered relatively Intact. Although mounted 1n the tallcone
area 1t had suffered substantial damage to the front of Its case at the
time of Impact. Water had penetrated the tape mechanism protective case
and corrosion products had attacked the tape where 1t was In contact with
the recording heads. The tape Itself had been broken by Impact forces at
the point where 1t crossed from the Inside of the reel to the recording
heads. The tape covered 30 minutes of aircraft operation, 12 minutes of
which related to the accident flight, beginning at the time of the first
engine start. The last half second of the accident flight recording was
degraded due to the tape being affected by corrosion products.
All air/ground transmissions were recorded satisfactorily and the CAM
provided a good recording of the total audio environment 1n the cockpit.
Crew conversation recorded by the CAM was readily Intelligible during
the ground operation of the aircraft. However, after take-off power was
applied a high level of background noise tended to mask the comments
made by the pilots. Considerable effort was required, Including
spectral analysis, signal enhancement and test recordings made in other
Westwinds, In order to complete a transcript of recorded information.
Extracts from this transcript are reproduced at Appendix C.
The CVR was not fitted, and was not required to be fitted, with an
underwater locator beacon (ULB).
1.11.2 Flight Data Recorder
The aircraft was fitted with a Fairchild 5424-501 Flight Data Recorder
(FDR) in accordance with requirements applicable at the time the aircraft
was entered on the Australian Register. This FDR is an analogue type that
records pressure altitude, indicated airspeed, magnetic heading, vertical
acceleration and VHF radio keying, against a time base. This information
is recorded by inscription on a stainless steel tape. Power is supplied
to the FDR from the No.2 Inverter via the Avionics Master Switch No.2.
The operator normally selected the Avionics Master Switches "ON" after
starting the first engine. The FDR was installed in the tallcone section
of the aircraft, however it also suffered substantial damage at impact.
After recovery of the FDR the tape was withdrawn from the unit and
although it had been torn during Impact, which precluded an exact mating
of the torn ends, the recorded data was extracted. A detailed read-out of
all recorded Information was conducted for a period of 10 minutes up to,
and including the impact sequence. This period covered approximately
seven minutes of ground operation and about three minutes from the start
of take-off to the end of reliable data.
The pressure altitude trace indicated that after becoming airborne the
aircraft climbed initially at 1700 feet/minute (fpm). The rate then
Increased and stabilised at 3300 fpm which was maintained to the maximum
recorded pressure altitude of 4700 feet, which corresponded to a height of
approximately 5000 feet above sea level. This was reached just over two
minutes after take-off, after which the aircraft entered a rapid descent
until impact occurred. The average rate of descent over the last 9
seconds of recorded data was in excess of 20,000 fpm.
The airspeed trace indicates that the aircraft accelerated normally and
stabilised at a climb speed of 240 knots. At 2 minutes 8 seconds after
take-off the airspeed Increased rapidly and there was some indication that
1t may have been stabilising in the region of 420 knots at the time of
impact. The recorder is calibrated to register indicated airspeed up to
450 knots.
Magnetic heading data was consistent with the aircraft taxy path and
take-off on runway 16 and the subsequent interception of the 126 radial of
the Sydney VOR. A left turn was commenced about two minutes after
take-off, which corresponds to the aircraft passing the 6 DME Sydney
position. However, after turning about eight degrees to the left, the
heading change stopped. After remaining steady for about 4 seconds the
aircraft heading commenced to change rapidly to the right. Heading
information was lost as the turn continued, with the last reliable

10
recording being obtained 15 seconds before the loss of reliable data from
the other parameters.
Estimates of the angles of bank achieved during the turn were computed.
During the Initial turn to the left the bank angle reached 20 degrees.
The aircraft then rolled to a wings level attitude before the angle of
bank rapidly Increased to the right, reaching 1n excess of 90 degrees.
The vertical acceleration force was normal until the point at which the
aircraft commenced the turn to the right. At this time It commenced to
Increase progressively, until shortly before Impact when the recorded
value exceeded the calibrated limit of 6g. The recorded Increase had been
1n the positive sense, I.e. following take-off the aircraft did not
encounter a vertical acceleration of less than the normal Ig.
The recorder was subject to annual and 1000 hour calibration checks. As
it was last calibrated on 20 February 1985 1t was within the annual limit.
However, the aircraft had flown a total of 1146 hours since that date. It
could not be established from the operator's records for how many of these
hours the particular recorder had been fitted to VH-IWJ, therefore its
calibration compliance status could not be determined. All recorded
information was found to be within required tolerances and the data
recovered was considered valid. Graphical presentation of the data 1s
shown at Appendix B.
The FDR was equipped with a ULB, which was mounted on the front of the FDR
casing. No signals had been received from this device during the search
operation. When the FDR was recovered, it was found that the ULB had been
disabled as a result of a localised heavy Impact, which distorted the case
of the unit and damaged the electronics module.
1.12 WRECKAGE AND IMPACT INFORMATION
The first pieces of wreckage were recovered less than 3 hours after the
accident at a position 116 degrees magnetic and 7 nautical miles by DME
from the Sydney navigation aids. The largest part of the aircraft to be
recovered was the outer two-thirds of the right wing including the
tip-tank. From the appearance of the Items recovered on that morning It
was evident that the aircraft had contacted the surface of the sea at very
high speed and had been violently destroyed. On 20 January 1986 the
remainder of the wreckage was located on the seabed about 1.5 km from the
position where the floating debris had been recovered. Information
obtained via a video camera confirmed the degree of destruction suffered
by the aircraft at the time of Initial Impact. Despite the recovery of
various components from the seabed, 1t was not possible to establish the
precise attitude of the aircraft at the time 1t struck the water.
1.12.1 Search and Recovery
The Distress Phase of Search and Rescue (SAR) procedures had been declared
at 0100 hours. Within 9 minutes of the disappearance of VH-IWJ, another
Pel-A1r Westwlnd, which had been preparing to depart for Melbourne, was
despatched to the last observed position of VH-IWJ. This aircraft was 1n
the area a short time later but was unable to detect any trace of the
missing aircraft. Meanwhile, the Senior Operations Controller (SOC) at
Sydney Airport had arranged for three SAR equipped helicopters to assist
1n the search for the aircraft. The NSW Water Police supplied two

11
launches and the Department of Aviation crash launch was also requested to
assist. An offer of help was also received from the Royal Australian
Navy, with advice that a helicopter had been launched from a vessel which
was 1n the vicinity.
The first helicopter was 1n the designated search area within 43 minutes
of the aircraft's disappearance and was joined a short time later by the
other elements of the search effort. Debris was first located at 0245
hours and the launches were directed to that location. The flotsam
consisted of the outer section of the right wing; items of freight; seat
cushions; life jackets; oxygen masks and tank; portions of both elevators
and other small pieces of the aircraft structure. A small quantity of
human remains was also recovered.
A combination of eyewitness evidence, the recollection of the Departures
Controller as to the last observed radar position, and the location of the
flotsam, was used to determine the most probable position of the remainder
of the wreckage. At the request of the Department of Aviation the Royal
Australian Navy provided a mlnehunter vessel, which was to be used to
locate the wreckage. Suitable equipment was carried to permit the
reception of signals from the ULB. The vessel arrived on-stat1on at 1526
hours on the day of the accident and Immediately commenced a search
pattern, utilising the ULB signal receivers In addition to the hull
mounted sonar equipment. However, throughout the entire search operation,
no signals were received from the ULB.
Searching continued until the afternoon of 12 October when adverse weather
and sea conditions halted operations for 3 days. During this period a
side-scanning sonar device, which was more suitable for the task, was
obtained and fitted to the mlnehunter.
A number of sonar contacts had been made during the early stages of the
operation. Water depth In the area precluded the use of conventional
diving techniques to obtain positive Identification of the various
contacts. Use was therefore made of two remote operated vehicles (ROV).
These were capable of diving to the depths required, recording the
contacts via television cameras, and capable of carrying out limited
recovery operations.
Searching activities continued, however a combination of adverse sea
states and equipment unservlceablHty frustrated the effort. Naval
support was ultimately withdrawn, but side-scan mapping was continued,
using a research vessel, until 22 November. At this time the operation
was suspended because of the lack of success 1n positively locating the
wreckage.
Arrangements were made for an American expert In the field of underwater
search and recovery of crashed aircraft to travel to Australia, 1n order
to advise on the usefulness of further searching. As a result of this
visit, a Sydney based towing and salvage firm was contracted to continue
the operation. Specialist men and equipment were provided from the USA,
and the Royal Australian Navy again supplied a mlnehunter vessel. On 20
January 1986, the wreckage of VH-IWJ was located at a depth of 92 metres
in position 118 degrees magnetic and 7.3 nautical miles by DME from the
Sydney navigation aids. The wreckage formed an elliptical pattern, some
200 metres long and 50 metres wide, aligned in a direction of 3288M. The
location was within the original search area. It was evident that the

12
degree of fragmentation of the aircraft; the limitations of the sonar
equipment used; and the lack of local expertise 1n the Interpretation
of sonar Information had precluded Its earlier discovery.
Recovery of the wreckage was co-ordinated by the towing and salvage
company, with additional vessels provided by the RAN and the Department of
Transport. This particular operation was commenced on 20 February 1986,
and both the FDR and the CVR were recovered that afternoon. Major
portions of both engines and various pieces of the aircraft structure and
components were recovered during the following two days. However, the
principal recovery vessel dragged Its moorings during a period of adverse
weather, and the cost and effort required to re-moor the vessel was
considered to be uneconomic. All recovery activity ceased on 23 February
1986.
1.13 MEDICAL AND PATHOLOGICAL INFORMATION
1.13.1 Medical Reports
Records maintained by the Department of Aviation showed that both crew
members had completed regular six-monthly medical examinations without
problems. The only Item of significance 1n Mr Haskett's records related
to a long standing mild electrical conduction defect of the heart, which
could cause an Irregularity of the heart beat. This conduction defect
could possibly have been associated with Ischaemlc heart disease, which
results from a restriction of blood vessels supplying the heart. Such a
condition places the person at a slightly greater risk of heart attack
than the average. No abnormality or Irregularity was noted during Mr
Haskett's last medical check, which was completed seven weeks prior to the
accident.
Mr Jackson had suffered a fractured skull in 1966, but there were no
associated problems arising from that particular Injury and he had no
significant medical history.
1.13.2 Pathology
There were Insufficient remains recovered for detailed pathological
examination. The autopsy was necessarily limited to the Identification of
the crew members.

1.14 FIRE
There was no fire associated with the development of the accident.

1.15 SURVIVAL ASPECTS

The accident was not survlvable.

13
1.16 TESTS AND RESEARCH
1.16.1 THE CREW
1.16.1.1 The Pilot 1n Command
Comprehensive Interviews were conducted with all the company Westwind
pilots and various management personnel. Mr Haskett was evaluated by
other company pilots as having average manipulative and instrument flying
skills for his level of experience. However, they considered that he
excelled as an Instructor by virtue of his personality, lecturing
technique and thorough knowledge of the aircraft and its systems. He was
a loyal and hard working employee who disliked inefficiency and laziness,
and expected nothing less than 100% effort from other company personnel.
Several company pilots reported that on check flights, Mr Haskett in his
role of check and training pilot, would introduce simulated systems
failures at any stage of the flight. Which systems were Involved and the
extent of the failure was mostly graded to take into account the
experience of the pilot undergoing check. A point made by almost all of
the company pilots was that Mr Haskett could be relied upon to Introduce a
unique or obscure failure that had not been covered previously with the
candidate. It was also his habit to require the candidate to handle
simultaneous systems failures but this was also graded to the experience
of the particular pilot. An example of the types of simultaneous and
complex failures given related to the loss of various navigation and
attitude Instruments, coupled with an engine failure, while the pilot was
carrying out an instrument approach at night.
Mr Haskett expected the company co-pilots to demonstrate their ability to
safely control the aircraft by reference to the emergency FAI, following
simulated failure of the FAI on the right Instrument panel. Some command
pilots were expected to make use of the rate of turn indicator, following
simulated failures of both FAIs on the left panel. To prevent the pilot
obtaining attitude information from the co-pilot's FAI, this Instrument
was covered, or the cockpit lighting on that side was extinguished.
Some of the company pilots had been expected to cope with this emergency
exercise immediately after a take-off at night.
1.16.1.2 The Co-Pilot
Mr Jackson had previously been based in Darwin with Pel-Air, where he
acted as pilot in command on Shorts 3-30 type aircraft. He had applied to
be transferred to Sydney when a vacancy became available. After arriving
1n Sydney to take up the position offered, he had apparently shown little
Interest in the company. He seemed to be having difficulty in reverting
from a pilot in command to a co-pilot, even though the company pilots
considered that the Westwind was a more desirable type to operate.
Company policy required a co-pilot to have accumulated a minimum of 500
hours on Westwinds before being eligible for command upgrading. When a
vacancy for a pilot 1n command had become available, Mr Jackson had lodged
an application for the position. He was to be the first co-p1lot to be
considered for the particular vacancy, because of his overall seniority 1n
the company.
Mr Jackson undertook an appraisal flight with Mr Haskett on 2 and 3
October 1985. Mr Haskett assessed his performance as unsatisfactory, on

14
the grounds of lack of knowledge of the various emergency procedures and
the aircraft systems. Counselling was given on these aspects by Mr
Haskett. Mr Jackson was also reminded that It was company policy to
permit a first-officer two attempts to upgrade to captain, and should the
second attempt be unsuccessful, the candidate remained as a co-pilot
Indefinitely. At the same meeting he was also counselled by the General
Manager on his overall attitude towards the company.
On 7 and 8 October, Mr Jackson had flown with another company check pilot,
who subsequently reported that In his opinion Mr Jackson had made
noticeable Improvement. However, he had still displayed some lack of
knowledge of various procedures, and the actions required in the event of
failures of some of the aircraft systems. During the flight Mr Jackson
was required to control the aircraft using the emergency FAI for attitude
guidance, following the simulated failure of the primary FAI. The check
pilot reported that Mr Jackson handled the exercise without difficulty,
and considered that he would make a suitable command pilot, following a
period of supervision.
Mr Jackson had recently been Informed of the unserv1ceabH1ty of the rate
of turn Indicator In VH-IWJ by one of the company pilots. The flight on
which the accident occurred was only the third occasion he had occupied
the left hand side control seat, and was the first occasion he had flown
VH-IWJ from that seat. It could not be determined whether Mr Haskett had
required him to fly using the rate of turn indicator during the appraisal
flight on 2 and 3 October. However, there was no doubt that Mr Jackson
had little or no recent experience In the use of this Instrument.
Mr Jackson had a disturbed sleep on the night preceding the accident
flight. This was evidently unusual for him as he was normally able to
relax quickly and he had adjusted well to the varying sleep patterns
Imposed on pilots who must work at night. He had spent most of the
previous day studying for the coming flight and he was aware that this was
probably his last chance to convince the Chief Pilot of his suitability
for upgrading. As he had not complained of any health problem, 1t Is
likely that this caused his unrest.
1.16.2 THE AIRCRAFT
1.16.2.1 Structure
The section of right wing recovered on the morning of the accident was
examined and determined to have failed 1n upward bending overload. The
wing malnspar failed just Inboard of the rib at Wing Station (WS) 93. This
position was about 4.5 metres from the outer edge of the wlngtlp fuel
tank. There was no damage to the wing leading edge. However, the
trailing edge and the lower rear section of the tip-tank displayed damage
consistent with the wing striking the water trailing edge first. No
evidence of any pre-existing damage to the wing could be found.
1.16.2.2 Engines
Examination of engine components confirmed that both engines were
operating at the time of Impact. The compressor blades of both engines
showed gross bending against the direction of rotation. This 1s
consistent with high rotational speed of the blades as they came Into
contact with the dlffuser casing. The combustion casing of the right

15
engine was torslonally buckled in the direction of rotation consistent
with gross braking loads as the compressor contacted the casing. The left
engine tailpipe was subjected to metallurgical examination to determine
Its temperature when buckled at Impact. This was determined to have been
1n excess of 500°C and Is also consistent with the engine operating at
high speed at Impact.
1.16.2.3 Control Surfaces
Although sections of the both elevators were recovered 1n the same
location as the other flotsam on the morning of the accident, little else
of the control surfaces or systems was recovered. Due to the other
evidence available, 1t 1s considered however that these components were
not of causal significance.
1.16.2.4 Stabiliser Trim
The horizontal stabiliser jack was recovered attached to a section of the
fuselage rear bulkhead and part of the support structure. The right hand
screwjack was broken at about half Its length and was missing. The left
hand screwjack rod end was torn from the horizontal stabiliser front spar
attachment point. The distance between rod ends on the left screwjack was
measured to determine the stabiliser position before Impact. It was
established by reference to the maintenance manual that the stabiliser was
In a position of -2.6 degrees, which was appropriate for the gross weight
and speed of the aircraft at the time.
1.16.3 OTHER RESEARCH
1.16.3.1 B1rdstr1ke
The services of an ornithologist were enlisted to ascertain the likelihood
of the aircraft being disabled as a result of a blrdstrlke. The
Information obtained revealed that many species of migratory birds fly at
night, up to an altitude of about 20000 feet. Although over forty species
of shoreblrds migrate between Asia and Australia, mainly 1n October, there
1s greater movement across Australia from the northwest rather than down
the Eastern seaboard. The largest bird likely to be encountered off the
East Coast at night during October Is the Black Swan whose maximum weight
for an adult Is 8.75 kg. These are common in southeastern Australia and
travel considerable distances at night up to altitudes of 10000 feet. The
conditions prevailing at the time of the accident would not have Impeded
bird flight 1n any significant way.
After recovery and transcription of the CVR tape 1t was evident that the
aircraft had not suffered a blrdstrlke.

1.17 ADDITIONAL INFORMATION

1.17.1. Criminal Allegations.
At the time of the accident a number of allegations had been made 1n the
various news media that Pe1-A1r was Involved 1n the transportation of
drugs. Because of these allegations, Investigations were carried out by
elements of the NSW Police Department. These Investigations were carried

16
out with the co-operation of, but Independent from, the Bureau of A1r
Safety Investigation.
A comprehensive forensic examination carried out by the Police found no
evidence to support any suggestion that any criminal attempt was made
to destroy the aircraft or Its crew.
1.17.2 Recorded Radar Information.
When VH-IWJ became airborne from Runway 16, the Departures controller was
able to monitor Its progress on radar by reference to the primary return
from the skin of the aircraft, and a secondary return generated by a
transponder In the aircraft. A primary return 1s generated each time the
radar antenna at the Airport receives a skin paint from an aircraft, and
the array completes one rotation 1n approximately 6 seconds. The antenna
which receives secondary returns Is mounted on the Route Surveillance
Radar Installation, which takes about 12 seconds to complete each
rotation. Information relating to the position and.height of the aircraft
1s updated at this rate.
Considerable difficulty was experienced In determining the exact position
at which the returns from the aircraft faded from the radar screen. The
last recorded secondary return was received before the aircraft commenced
Its left turn at about the 6 DME position. However, the controller had
observed primary paints from the aircraft as 1t made the turn. The loss
of secondary radar Information during a turn 1s a known phenomenon,
occurring as the transponder antenna 1s shielded by the aircraft
structure. At the present time at the major airports 1n Australia, only
the secondary radar Information 1s recorded. As a result, the point at
which the controller assessed the aircraft returns had faded depended on
his recollections, and could not be positively verified. The likely area
1n which the aircraft struck the water was therefore unable to be defined
as accurately as desired. This 1n turn led to a dilution of the search
effort, with the available resources requiring to be spread over a larger
area.

1.18 NEW INVESTIGATION TECHNIQUES

1.18.1 Use of Hypnosis.
One of the principal eye witnesses was a gaol warder. His Initial
statement on his recollection of the manoeuvres of the aircraft was clear
and apparently accurate, however he was unable to recall the whole of the
flight path. He agreed to be placed under hypnosis to ascertain whether
his memory of the event could be Improved.
The exercise was carried out by a NSW Police Department Scientific Squad
officer specially trained and approved to place subjects under hypnosis.
The Interview was conducted by this officer 1n the presence of
Investigators. The witness took some time to relax sufficiently to allow
himself to become hypnotised, however he then showed graphic recall of the
accident. His Initial statement had referred only to the observed descent
of the aircraft, but he was now able to remember events leading to that
descent. He described that he saw the aircraft commence a turn to the
left, then roll to the right past the vertical position before diving
towards the sea. This was the first Indication available to the

17
Investigation that the aircraft had rolled Into the descent, rather than
pitched nose-down from a wings-level attitude. This aspect provided
valuable assistance to the Investigation, at a time when there was
considerable doubt that the flight recorders would be recovered.
Following the recovery of the FDR, the sequence of events as described by
the witness was proved to be accurate. This was further confirmed by the
results of the experiments carried out 1n the flight simulator, as
described at Para 1.18.2.
A considerable amount of research has been carried out Into the use of
hypnosis during criminal Investigations. Similar research 1s being
undertaken for Its use in aircraft accident Investigations. There are
conflicting reports of the usefulness of the technique, as it has been
shown scientifically that hypnosis rarely enhances memory. However, there
is evidence that hypnotic Interviews are most likely to reveal significant
information when witnesses are genuinely motivated towards the use of the
technique. This was the first occasion in which hypnosis had been applied
in this country to assist an aircraft accident investigation, and the
results were encouraging.
1.18.2 Pilot Performance Experiments In Flight Simulator.
It became apparent during the investigation that the check pilot had
possibly simulated failures of all FAIs shortly after the aircraft was
established in a steady climb. This would leave the pilot flying the
aircraft with no direct attitude instrument reference, and commit him to
fly the aircraft with no gyro attitude Instrument, In an environment where
there were no external visual references. Such a task, while difficult,
should be within the capabilities of a properly trained pilot, providing
the remaining Instruments are functioning correctly. However, the rate of
turn indicator in this aircraft was operating In the reverse sense. The
effects on pilot performance under these demanding circumstances was
unknown.
In order to obtain specific Information on the difficulties of maintaining
aircraft control under the described circumstances, a series of
experiments was carried out in a flight simulator. The results of the
experiments were then used to animate an aircraft image on the Bureau's
computer graphics system in order to observe the flight paths 1n three
dimensions and in real time.
The simulator used was a Boeing 707-338 model. It was configured with a
similar Instrument panel to that 1n VH-IWJ, except that the rate of turn
indicator was a separate Instrument with a considerably larger pointer.
For the purpose of the exercise, a 7 channel pen recorder was Installed,
and modifications were made to enable the sense of the rate of turn
Indicator to be reversed as desired.
The program for the experiment was devised by the Bureau's human
performance experts, 1n conjunction with flight recorder and simulator
specialists. The pilots used were 9 qualified Boeing 707 pilots. They
were each required to execute a take-off followed by a "16 West Maitland
One" departure from Sydney, with the Introduction of limited panel
operation shortly before the required turn at 6 DME. The exercise was
then repeated, but with the sense of the rate of turn indicator reversed
at the point of Introduction of the limited panel condition.

18
The results of the study showed that all of the pilots maintained adequate
control of the aircraft when the rate of turn Indicator was operating
correctly. However, with the sense of this Instrument reversed, 3 pilots
lost control and "crashed" the simulator. In each case, control was lost
after the commencement of the left turn, with the aircraft finally
executing a steep turn to the right. The final Impact was at an angle in
excess of 50 degrees nose down, and at an airspeed In excess of 500 knots.
None of the pilots made any attempt to reduce engine thrust, and all
Impacts were with climb thrust still applied.
The average time taken for the aircraft to descend from about 5000 feet to
sea level was 12 seconds. In addition, 4 other pilots entered a right
turn following their Initial turn to the left. These pilots were able to
retain control, and subsequently were able to turn again to the left. It
was noted that all pilots who turned to the right did so an average of 6
seconds after commencing the planned turn to the left. This finding was
of considerable interest, as it had been believed that with the turn
Indicator showing a right deflection when the left turn was commenced, the
pilot would naturally apply more left bank input to achieve the desired
result. It was therefore expected that if control were lost, it would
involve an Increasing bank to the left. The simulator experiments showed
unequivocally that this was not the case.

2 ANALYSIS
2.1 General
The Initial preparations for the flight were apparently normal. The
unserviceabllitles listed in the maintenance documentation relating to the
rate of turn Indicator and the altitude alerting system would not, in
themselves, have affected the ability of the crew to safely conduct the
flight. The take-off and Initial climb also appeared to be normal.
However, control of the aircraft was lost just over 2 minutes after
take-off, as a turn, which should have taken the aircraft left through 129
degrees, was commenced.
This analysis evaluates the relevant areas of the witness, engineering and
flight recorders evidence and examines the possible operational reasons
for the loss of control and the subsequent descent into the sea.

2.2 The Aircraft

Appropriate maintenance documentation relating to the aircraft was In
order, and all mandatory maintenance and Inspections were recorded as
having been carried out. There was no evidence that the aircraft was
other than serviceable prior to the flight, with the exception of the
altitude alerting system and the rate of turn indicator. The aircraft had
operated satisfactorily with a defect in the rate of turn indicator for
almost 12 months.
Despite the fact that the Indicator was faulty, no effort had been made to
positively alert the pilots to Its continuing presence. This could have

19
been achieved by the placing of a placard near the face of the Instrument,
or by the pulling and locking of the appropriate circuit breaker.
The examination of the wreckage recovered together with the Information
obtained from the FDR and CVR did not reveal any evidence to Indicate that
the aircraft was not capable of normal operation at the time of departure
from Sydney. Both engines were operating at high rotational speeds at the
time of Impact, and 1t was considered that the circumstances of the
accident were not consistent with those that might be expected with an
engine related problem.

2.3 The Crew

Both pilots were suitably licenced and qualified to undertake the flight.
Mr Haskett had considerable experience on the aircraft type both 1n the
normal operating and training roles. Mr Jackson had substantial
experience on the type as a co-pilot, although this was to be only his
third flight while occupying the left control seat. On the previous
occasions he had not been flying VH-IWJ.
With the exception of Mr Jackson's disturbed sleep pattern on the evening
of the flight, neither pilot had any known medical or psychological
problem which might have affected their ability to safely operate the
aircraft. The cause of Mr Jackson's sleeping difficulty was not
determined, but may have been related to some perceived stress, with
reference to the importance of the flight on his future progress 1n the
company. There was evidently nothing 1n his manner or appearance during
the period before or on the night of the flight to suggest that he was not
capable of performing his assigned duties.
There were insufficient human remains recovered to allow any detailed
Information to to be obtained from the autopsy examinations.

2.4 Meteorological Conditions

The sky 1n the area was relatively free of cloud, winds were light and
visibility was unobstructed. There was no known turbulence or other
meteorological phenomena that might have affected the aircraft. Weather
conditions were therefore not considered to have had any bearing on the
development of the accident.

2.5 The Accident Sequence

The evidence obtained from eye witnesses, recorded radar information and
the FDR Indicated that the aircraft was tracking 1n accordance with the
assigned airways clearance. Shortly after commencing a turn at 6 DME,
control of the aircraft was lost and a steep descent followed. Sudden
loss of control of an aircraft under the circumstances was considered
likely to have been caused by one of the following Influences.
(a) Structural failure of the alrframe
(b) Uncommanded elevator trim Inputs.

20
(c) Sabotage
(d) Collision with another aircraft or object
(e) Pilot Incapacltatlon
(f) Suicide
(g) Spatial dlsorlentatlon
2.5.1 Structural Failure of the Alrframe.
The aircraft type did not have any history of structural problems. VH-IWJ
had been maintained 1n accordance with the approved schedules, and had
flown a lower number of hours than Its contemporaries In Australian
operations.
Eye witness evidence Indicated that the aircraft descended steeply but
without noticeable movement about the longitudinal axis. The landing
lights were visible, and formed the basis of this evidence. The lights
were located on the front of the wing tip fuel tanks, thus It was apparent
that neither wing had failed 1n flight. Portions of both elevators were
recovered In the main area of floating wreckage, Indicating that they had
been attached to the alrframe at or close to the point of Impact. In
addition, no sounds that could possibly be associated with an In-flight
structural failure were detected on the CVR tape, nor was there any
comment from the crew to Indicate a sudden control problem. None of the
components recovered showed any sign of failure other than by overload
forces.
2.5.2 Uncommanded Elevator Trim Inputs.
There are known cases of aircraft accidents resulting from a situation
known as "runaway elevator trim". Typically, the trim runs away to the
full nose-up or full nose-down position, leading to loss of control and/or
overload failure of the structure. None of these accidents have Involved
the Westwlnd type.
In the case 1n point, the most serious situation would result from a
nose-down trim Input. Such an Input would result 1n a strong negative "g"
acceleration as the aircraft pitched down. The FDR foil Indicated that
there was a progressive Increase In positive "g" loadings, and eye witness
evidence Indicated that the aircraft rolled, rather than pitched, Into the
descent. In addition, the horizontal stabiliser jack was found to be 1n
the mid-range of Its travel. Again, no comments were recorded from the
crew to Indicate such a problem occurred.
2.5.3 Sabotage.
The most likely methods for any sabotage attempt were considered to be an
explosive device or a toxic chemical or gas container concealed In the
freight. The Investigation disclosed no reason for any such attempt on
this aircraft or crew, and the CVR tape did not record sounds of an
on-board explosion or unusual comment from the crew. Forensic testing
carried out by the NSW Police Department also failed to reveal any
evidence to support a sabotage attempt.

21
 2.5.4 Collision with Another Aircraft or Object.
The analysis of recorded radar Information together with evidence from the
various ATC personnel on duty indicated that no other aircraft was in the
area at the time. The sounds of a bird or other object striking the
aircraft with sufficient force to disrupt the structure would have been
recorded on the CVR tape. No such noises were recorded.
2.5.5 Pilot Incapacltatlon.
Both pilots were apparently In good general health, although on the
evening prior to the flight Mr Jackson had not slept as well as normal.
It was considered possible that one of the pilots may have suffered a
sudden illness or incapacity, such as a heart attack, and had slumped
forwards onto the controls. Such a movement would result 1n a similar
movement to a runaway trim situation, with a large negative "g" input. As
previously mentioned, the "g" forces were positive, and there was no
recorded comment or exclamation as might be expected if a crew member
collapsed. The majority of Pel-Air pilots also believed that if either
pilot slumped forward, the other had sufficient strength to pull him
clear of the controls.
2.5.6 Suicide.
No evidence was found to suggest that either or both pilots had
contemplated such an attempt.
2.6 Spatial Disorientation.
In the absence of any evidence to Indicate that the loss of control was
related to any of the previous considerations, it seems likely that the
accident resulted from the crew losing their awareness of the attitude of
the aircraft.
Spatial dlsbrientation describes a situation in which a pilot fails to
sense correctly the position, motion or attitude of his aircraft. It
results from a conflict of information from his senses, primarily those of
vision and balance. Alternatively, where there are Insufficient visual
cues, the information from the sense of balance is all that is available
to determine orientation. The sense of balance Is extremely unreliable
and, depending on the circumstances of flight, may provide erroneous
information to the pilot. If there is no visual means with which to
cross-check the Information from the balance senses, the pilot may be
unaware that it is in error. His perception of the aircraft orientation
in space may thus be Incorrect, and he will not be aware that this Is so.
Both pilots were qualified to operate the aircraft under Instrument
Meteorological Conditions. The night was dark, and there would have been
no visible horizon as the aircraft tracked out to sea. Under these
conditions the crew would have been required to monitor and control the
attitude of the aircraft solely by reference to the flight instruments.
The aircraft had a comprehensive array of Instruments, including two FAIs
on the left panel and one on the right. On a routine flight 1t would be
expected that if both indicators on the left side failed, or 1f the pilot
had difficulty with control, the pilot in the right seat would monitor the
situation or assume control If necessary. The FAIs were powered from
separate sources, and the simultaneous failure of all three was extremely

22
unlikely. No evidence was found to indicate that any of the FAIs had
failed for technical reasons.
It 1s difficult to conceive how two experienced pilots would lose control
of the aircraft 1n normal flight conditions if all the Instruments
usually available for attitude control were functioning properly.
2.6.1 Simulation of Flight Instrument Unservlceablllty.
Information recovered from the CVR indicated that soon after the required
checks following take-off had been completed and the aircraft was
established 1n a normal climb, the check pilot stated his intention to
simulate an emergency instrument situation. The simulation was probably
intended as a test of the ability of Mr Jackson to operate the aircraft
under limited Instrument conditions. Evidence obtained from other company
pilots indicated that Mr Haskett was known to Introduce such an exercise
by failing both FAIs on the left instrument panel. This would require the
pilot being checked to assess the attitude of the aircraft by integrating
the information presented by the remaining flight Instruments, 1n order to
give a mental picture of the position of the aircraft with reference to
the natural horizon. To counter any tendency on the part of the pilot to
glance at the FAI on the right Instrument panel for additional guidance,
Mr Haskett was known to cover this Instrument, or to turn the lighting
down on that side of the cockpit. Although this ensured that the pilot
flying the aircraft had no single attitude reference Instrument, 1t also
deprived Mr Haskett of an instant check of aircraft attitude. If he had
adopted such a procedure on this occasion, he lost the ability to readily
monitor Mr Jackson's performance of the task, because of the lack of a
natural or artificial horizon reference.
If the limited panel situation had been simulated as discussed above, Mr
Jackson would have had to make use of the rate of turn indicator 1n order
to assess the bank angle of the aircraft during the turn. Although he had
recently been informed by another company pilot of the defect in the
Instrument, it was likely that he Inadvertently overlooked It under the
high workload Involved as he concentrated on the handling of the aircraft.
It was apparent that the loss of control occurred shortly after the
planned turn to the left had been commenced, and followed a steep bank to
the right. It was likely that neither pilot was aware of the attitude of
the aircraft until it had reached an extreme point, possibly at or about
the inverted position and with the nose well below the horizontal. From
this position, there was evidently insufficient height remaining 1n which
the pilots could effect a recovery.

3. CONCLUSIONS
Findings.
1. The pilots were correctly licenced and were suitably experienced and
qualified to undertake the flight.
2. There was no evidence that either pilot suffered any sudden Illness
or Incapacity which might have affected his ability to safely control
the aircraft.

23
3. The aircraft had been maintained 1n accordance with the approved
schedules, and there was nothing to suggest that It was not capable
of normal operation at the time of departure from Sydney Airport.
4. The weight and centre of gravity of the aircraft were estimated to be
within the limits specified In the approved Flight Manual.
5. The provision of air traffic control services was not a factor 1n the
accident.
6. There were no meteorological conditions that might have contributed
to the accident.
7. The aircraft was technically rendered un-a1rworthy by virtue of a
defect In the rate of turn indicator, which formed part of the FAI on
the left hand side Instrument panel. The presence of the defect had
been known for almost 12 months, and all attempts to rectify the
deficiency had been unsuccessful. The operating company had not made
application to have the defect Incorporated Into the approved
Permissible Unservlceability Schedule.
8. The operating company had made no effort to alert pilots to the
continuing presence of the above defect, by placarding or removing
the electrical power supply to the Instrument.
9. The presence of the defect did not compromise the ability of the
crews to operate the aircraft safely under normal conditions.
10. The pilot 1n command intended to use the flight to assess the
performance of the co-pilot, who was being considered for up-grading
to command status.
11. The pilot in command was known to simulate emergency Instrument
flight conditions while checking company pilots. These simulations
took the form of failures to the FAIs on the left instrument panel,
and the masking of the Indicator on the right by covering or the
removal of Instrument lighting.
12. It was likely that on this occasion that the simulated failures
referred to above were given shortly before the aircraft reached a
position of 6 DME from Sydney. At this time the pilot 1n command had
no external reference by which to monitor the attitude of
the aircraft in relation to the horizon.
13. Shortly after commencing a planned turn to the left at a height of
about 5000 feet, the aircraft entered a rapid turn to the right and
rolled, probably to a nose-down Inverted position, before entering a
steep descent.
14. The pilots did not recover control of the aircraft before impact with
the water.
15. Experiments conducted 1n a simulator confirmed that the observed
loss of control was typical of that which could occur when the pilot
had no single attitude reference Instrument, and at a time when the
rate of turn indicator was operating 1n the Incorrect sense.

24
Relevant Events and Factors.
1. There was a known malfunction of the rate of turn Indicator.
2. The pilot 1n command possibly simulated simultaneous failures of
all three flight attitude Indicators.
3. There were no external references by which the crew could assess the
attitude of the aircraft.
4. A loss of control of the aircraft occurred at a height of about 5000
feet.
5. The crew did not recover control of the aircraft prior to Impact
with the sea.

4. SAFETY RECOMMENDATIONS
4.1 When the likely circumstances of the accident had been established,
the following recommendation was made to the Department of Aviation:
"That consideration should be given to prohibiting comprehensive
simulated flight Instrument failures while training and checking
at night and In non-Visual Meteorological Conditions."
The Department of Aviation subsequently advised that the recommendation
had been accepted, and appropriate steps had been undertaken to alert the
aviation Industry.
4.2 Because of the difficulty 1n determining the final flight path and
subsequently locating the wreckage of the aircraft, due 1n part to the
failure of the Underwater Locator Beacon on the Flight Data Recorder, and
the lack of recorded primary radar Information, the following
recommendations were also made to the Department of Aviation:
(a) "That consideration should be given to requiring the fitment of
Underwater Locator Beacons to Cockpit Voice Recorders as well
as to Flight Data Recorders In aircraft required to carry such
devices."
(b) "That consideration should be given to the provision of
suitable equipment to permit the recording of primary radar
Information from Terminal Area and Route Surveillance Radar
Installations."

25
 APPENDIX A
Deportment of Aviotion.Auttrolio RWY 16 NORTH
Chongei: WIM SIDS SYDNEY (KINGSFORD SMITH), NSW
DME INTERCEPT DISTANCES ARE A P P R O X I M A T E FREQUENCIES
(-WEST MAITLAND WILLIAMTOWN-, 115.4 317
VOR 1)3.7
NDB 224
o— ATIS

ACD 127.5
DME 39 SMC 121.7 122.3IA)
TWR 120.5 279.5
123.0 263.6
DEP
125.3 2B5.6

STANDARD INSTRUMENT DEPARTURES

16 WEST MAITLAND (WMD) ONE 16 WILUAMTOWN (WLM) ONE
Maintain runway heading • Maintain runway heading
As soon as possible after leaving 500 FT • At toon at pottible after leaving 500 FT.
turn LEFT and intercept 126 SY VOR turn LEFT and intercept 126 SY VOR
At 6 DME SY turn LEFT heading 357° • At 6 DME SY turn LEFT heading 357°
Intercept 177 WMD VOR . Intercept 015 SY VOR
• Track to WLM and at flight planned
Track to WMD and as flight planned
16 WILUAMTOWN (WLM) TWO
16 WEST MAITLAND (WMD) TWO
Maintain runway heading • Maintain runway heading
• At 500 FT.turn LEFT heading 120°
At 500 FT turn LEFT heading 120"
• At 1500 FT. turn LEFT heading 360°
At 1500 FT turn LEFT heading 360°
• Intercept 015 SY VOR
When crossing 023 radial SY VOR turn • Track to WLM and at flight planned
LEFT heading 340°
Intercept 003 SY VOR
Track to WMD and as flight planned

AIP AUSTRALIA RWY 16 NORTH

MAIM 1911 SYDNEY (KINGSFORD SMITH), NSW 2f.
S ID
 VH-IWJ FAIRCHIID 5«<f F.D.R DATA READOUT
FROM TAKE-OFF CLEARANCE TO IMPACT
APPENDIX B

*
MAGNETIC

INDICATE; AIRSPEED

PRESSURE ALTITUDE

MICROPHONE KEYING
nn

VERTICAL ACCELERATION

3700 4500 tTO'O 4900 5100 6100

ELAPSED TIME ISECONOSI
 APPENDIX C

TRANSCRIPT OF COCKPIT VOICE RECORDER, RECOVERED FROM IAI WESTWIND VH-IWJ

AND RELATING TO AN ACCIDENT ON 10 OCTOBER 1985

LEGEND

CAM Cockpit area microphone voice or sound source

CAM - 1 Occupant In right hand seat
CAM - 2 Occupant In left hand seat
CAM - ? Voice not Identified
SY TWR- Sydney Aerodrome Controller
SY DEP- Sydney Departure Controller
( —) Unintelligible word(s)
// // Explanatory note
{ ) Words open to other Interpretation
Significant pause

28
 INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

Time Source Content Source Content

GMT

1454:38 CAM-1 India Whiskey

Juliet's ready
1454:40 SY TUR India Whiskey Juliet
contact one two six
decimal one airborne
clear for take-off
1454:45 CAM-1 India Whiskey Juliet
1454:47 CAM-1 anti-skid
1454:48 CAM-2 Is on lights out
1454:49 CAM-1 pltot and angle of
attack
CAM-2 1s on
1454:52 CAM-1 annunciators panel
1454:56 CAM-2 1s clear apart from
the pltot light and
( —)
1454:59 CAM-1 landing lights and
strobes are on radar
er we wont worry
about transponder 1s
on radars to standby
transponder Is on
thanks I forgot 1t
1455:09 CAM-2 yep
1455:10 CAM-1 urn VLF I'll engage
your headings one
ninety now
1455:18 CAM-2 yep
1455:19 CAM-1 .flight control sorry
CAM-2 full and free

29
 INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

Time Source Content Source Content

GMT

1455:22 CAM-1 checks are complete

and we are clear for
take-off
1455:25 CAM-2 okay thirteen
twenty-five thirty
three and ninety six
four maximum (level)
ninety eight
1455:31 CAM //engine noise
Increases//
1455:38 CAM-2 set the power
1455:43 CAM-2 eighty knots
1455:44 CAM-1 you have control
1455:50 CAM-1 V one
1455:54 CAM-1 rotate
1455:58 CAM-1 positive climb
1455:59 CAM-2 brakes on gear up
1456:04 CAM //reduction 1n
noise as
undercarriage Is
retracted//
1456:07 CAM-2 yaw damper
CAM-1 Is 1n
1456:10 CAM-1 Goodday Sydney
Departures India
Whiskey Juliet 1s
climbing to flight
level three seven
zero and ah looking
for a short cut to
Brisbane
1456:21 CAM-2 and flap away

30
 INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

Time Source Content Source Content

GMT

1456:22 SY DEP India Whiskey Juliet

good morning you're
Identified have you
got Omega
1456:26 CAM-1 Affirmative sir

1456:28 SY DEP Ok ah probably get

direct Brisbane will
advise
1456:31 CAM-1 India Whiskey Juliet

1456:35 CAM-2 and after take-off

checks when you're
ready
1456:39 CAM-1 and er urn away
we go gear
CAM //background noise -
altitude alert//
1456:45 CAM-2 1s up and Indicating
1456:47 CAM-1 flaps
1456:48 CAM-2 up and Indicating
1456:49 CAM-1 yaw damper
1456:50 CAM-2 1s engaged
1456:52 CAM-1 anti-ice
1456:55 CAM-2 1s off
1456:57 CAM-1 climb power
1457:02 CAM-2 set
1457:04 CAM-1 pressurisatlon
1457:07 CAM-2 set and climbing

31
 INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

Time Source Content Source Content

GMT

1457:12 CAM-1 checks complete

CAM //background noises -
altitude alert//
1457:31 CAM-1 well we will just do
some emergency er
(flying checks)
1457:36 CAM-2 okay
1457:49 CAM-2 six DME 1t was left
on three five seven
wasn't 1t
1457:52 CAM-1 that's right just
coming up to six now
1457:59 CAM-1 you've lost (these
two)//(th1s thing)?//
CAM //background noise -
altitude alert//
1458:05 CAM-? {Yeah I know where
are we )
1458:13 CAM-? (pull)
CAM //airflow noise
Increases//
1458:24 END OF RECORDING

32
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