VH-AAV Crash - Investigation and Aftermath

Investigation and Aftermath

The accident had a profound impact upon the community in the small country town of Temora, as all 12 passengers killed were residents of the surrounding districts. The victims included a local police officer, his wife and infant son who had been airlifted to Sydney five days before the accident as the baby had required urgent medical treatment for a respiratory condition. The family were returning home aboard flight 4210. It was revealed by the Sydney Morning Herald the day following the accident that a 13th passenger had cancelled her booking on the flight the day before the accident.

The initial accident investigation was conducted by the Air Safety Investigation Branch of the Department of Transport and was released in September 1981. While this investigation could not conclusively determine the cause of the accident, a number of conclusions were made about the events leading to the crash. These included the aircraft being over the maximum allowable weight by some 128 kilograms (280 lb) at the time of departure due to a company procedure of using standard (estimated) passenger weights, as well as an amendment to the company's Operations Manual advising pilots to use a reduced power setting for takeoff to reduce wear on the aircraft engines which was not approved by the Department of Transport. When combined with the ambient temperature of 39 °C (102 °F) and an overweight aircraft, these factors adversely affected the single pilot's workload and reduced the single engine performance of the King Air to a critical point. The investigation determined the left engine had likely failed due to water contamination found in the aircraft's fuel tanks, but source of the contamination was not established.

A board of inquiry, headed by Sir Sydney Frost, was convened on 1 December 1981, sitting over 90 days. On 27 January 1982, the board heard evidence from a former chief pilot of Advance Airlines who told the inquiry that on days when the temperature exceeded 28 °C (82 °F) (such as the day of the accident), it would be necessary to use a higher power setting than that advised in the company Operations Manual to ensure a safe takeoff, and that in his interpretation of the manual, this was quite clear. He also told the inquiry that Advance checked for water in the fuel system each time the aircraft was refuelled, when he operated the aircraft on scheduled flights the day prior to the accident, the aircraft performed "quite well". In 1983 the board of inquiry published their findings, attributing the cause of the accident to the presence of water in the fuel tank leading to the engine failure, and pilot error. The inquiry recommended that commercial aircraft operating in Australia with more than nine passengers should be operated by two pilots, which was accepted by aviation regulators.