1946 Australian National Airways DC-3 crash
Encyclopedia
On 10 March 1946 a Douglas DC-3
Douglas DC-3
The Douglas DC-3 is an American fixed-wing propeller-driven aircraft whose speed and range revolutionized air transport in the 1930s and 1940s. Its lasting impact on the airline industry and World War II makes it one of the most significant transport aircraft ever made...

 aircraft departed from Hobart
Hobart
Hobart is the state capital and most populous city of the Australian island state of Tasmania. Founded in 1804 as a penal colony,Hobart is Australia's second oldest capital city after Sydney. In 2009, the city had a greater area population of approximately 212,019. A resident of Hobart is known as...

, Australia
Australia
Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area...

 for an Australian National Airways
Australian National Airways
Australian National Airways was Australia's predominant carrier from the mid-1930s to the early 1950s.-The Holyman Airways Period:On 19 March 1932 Flinders Island Airways began a regular aerial service using the Desoutter Mk.II VH-UEE Miss Launceston between Launceston, Tasmania and Flinders...

 flight to Melbourne
Melbourne
Melbourne is the capital and most populous city in the state of Victoria, and the second most populous city in Australia. The Melbourne City Centre is the hub of the greater metropolitan area and the Census statistical division—of which "Melbourne" is the common name. As of June 2009, the greater...

. The aircraft, with both engines operating, crashed into the sea less than 2 minutes after takeoff
Takeoff
Takeoff is the phase of flight in which an aerospace vehicle goes from the ground to flying in the air.For horizontal takeoff aircraft this usually involves starting with a transition from moving along the ground on a runway. For balloons, helicopters and some specialized fixed-wing aircraft , no...

.

All twenty-five people on board the aircraft died. An inquiry closely examined three different theories but found there was insufficient evidence to determine any one of them as the cause.

At the time of the crash this was Australia's worst civil aviation
Civil aviation
Civil aviation is one of two major categories of flying, representing all non-military aviation, both private and commercial. Most of the countries in the world are members of the International Civil Aviation Organization and work together to establish common standards and recommended practices...

 accident. It remained the worst until the crash of the Douglas DC-4 Amana
ANA Skymaster Amana crash
The ANA Skymaster Amana crash was an aircraft crash which occurred near Perth, Western Australia on 26 June 1950. At 9:50pm, a Douglas DC-4 Skymaster aircraft named Amana, operated by Australian National Airways, departed Guildford aerodrome in Perth, Western Australia, heading for Adelaide...

 in 1950.

The flight

On 10 March 1946 the aircraft arrived at Cambridge aerodrome
Cambridge Aerodrome
Cambridge Aerodrome , also known as Cambridge Airport, is a minor airport serving Hobart, Tasmania, Australia. It is located only a few kilometres from the primary airport, Hobart International Airport....

 at 8:15 pm local time, about four hours late. The return flight to Essendon Airport
Essendon Airport
Essendon Airport is located at Essendon, in Melbourne's northern suburbs, Victoria, Australia. It is located next to the Tullamarine Freeway on , from the Melbourne Central Business District and from Melbourne Airport.-History:...

 was scheduled to depart at 4:50 pm, but did not occur until 8:50 pm.

On board were 21 passengers, 3 pilots and an air hostess.
Flight attendant
Flight attendants or cabin crew are members of an aircrew employed by airlines primarily to ensure the safety and comfort of passengers aboard commercial flights, on select business jet aircraft, and on some military aircraft.-History:The role of a flight attendant derives from that of similar...

  Douglas DC-3 (and C-47) aircraft were normally crewed by two pilots but the third seat in the cockpit
Cockpit
A cockpit or flight deck is the area, usually near the front of an aircraft, from which a pilot controls the aircraft. Most modern cockpits are enclosed, except on some small aircraft, and cockpits on large airliners are also physically separated from the cabin...

 of VH-AET was occupied by a supernumerary
Supernumerary
A Supernumerary is an additional member of an organization. A supernumerary is also a non-regular member of a staff, a member of the staff or an employee who works in a public office who is not part of the manpower complement...

 pilot who was making his first flight with the airline. The weight of the aircraft was about 900 pounds (408 kg) below the maximum authorised weight.

The takeoff was into a light southerly wind towards Frederick Henry Bay
Frederick Henry Bay
Frederick Henry Bay is a body of water in the southeast of Tasmania, Australia. It is located to the east of the South Arm peninsula, and west of the Tasman Peninsula. Towns on the coast of the bay include Lauderdale, Seven Mile Beach, Dodges Ferry and Primrose Sands...

 and the sea. Observers at the aerodrome reported that the takeoff was normal, and both engines were operating perfectly.

Witnesses in the vicinity of Seven-Mile Beach estimated that the aircraft reached a height of about 400 ft (122 m) before turning slightly and descending. The aircraft cleared the land and crashed into Frederick Henry Bay about 300 yards (275 m) beyond the water's edge and a mile (1.6 km) from the western end of Seven-Mile Beach. After takeoff it flew for less than 2 minutes and covered a distance of only 2.9 nautical miles (5.4 km).

Wreckage

On learning of the crash at nearby Seven-Mile Beach employees of Australian National Airways raced from Cambridge aerodrome to lend assistance. About 45 minutes after the crash the rear fuselage
Fuselage
The fuselage is an aircraft's main body section that holds crew and passengers or cargo. In single-engine aircraft it will usually contain an engine, although in some amphibious aircraft the single engine is mounted on a pylon attached to the fuselage which in turn is used as a floating hull...

 came to the surface a short distance off-shore. Donald Butler, one of the employees, feared the air hostess might still be trapped in her seat in the rear of the fuselage. He took a length of rope, swam out to the floating piece of structure, attached the rope to the tailwheel and then swam back to the beach. The rear fuselage was dragged ashore but there was no-one inside.

Diver Glen Thorne found pieces of wreckage scattered over a wide area of the sea bed. The aircraft had disintegrated and there were few recognisable pieces of structure. Key parts of the wreckage were eventually recovered from the seabed by Thorne working from Royal Australian Navy
Royal Australian Navy
The Royal Australian Navy is the naval branch of the Australian Defence Force. Following the Federation of Australia in 1901, the ships and resources of the separate colonial navies were integrated into a national force: the Commonwealth Naval Forces...

 ship HMAS Huon
Huon River
The Huon River is the fourth largest river in Tasmania, Australia. It is 170 km in length, and runs through the fertile Huon Valley. From Scotts Peak Dam at Lake Pedder where it begins, it flows south-east to the Tahune Airwalk, where the Picton River joins, before heading through the rural...

. The wreckage was in about 18 ft (5.5 m) of water.

Bodies

In the 12 hours after the crash 7 bodies, including that of the chief pilot, were washed ashore. The next day, another 3 bodies were washed ashore. The bodies were badly mutilated and either naked or clad only in vestiges of underclothing, indicating the severity of the impact with the water. One body was missing a leg. A head, severed from its body, was recovered in the vicinity.

The bodies of 21 of the 25 people on board were eventually recovered from the beaches around Frederick Henry Bay. The remaining 4 bodies were never found. One body was found on the beach at Sandford
Sandford, Tasmania
Sandford is a town located on the South Arm Peninsula on the outskirts of Hobart, Tasmania, Australia. It is part of the City of Clarence.Sandford is also home to the Sandford Rifle Club which is located in Rifle Range Road....

, about 5 miles from the point of impact. The body of the supernumerary pilot was not identified until 19 days after the accident.

Two years after the accident, a human thigh-bone was found on Seven-Mile Beach. Police believed the bone came from one of the bodies never recovered.

Investigation

The Director-General of Civil Aviation promptly established a panel to investigate the accident. The panel was chaired by John Watkins. The panel identified 25 possible causes of the accident. In its interim report to the Director-General on 20 March 1946 the panel reduced these possible causes to 3:
  • Inadvertent engagement of the automatic pilot
    Automatic Pilot
    Automatic Pilot was a San Francisco, California band. Created in 1980 by members of the San Francisco Gay Men's Chorus, they were described by The Advocate as "a non-official offshoot" of SFGMC along with three official subgroups...

     - The autopilot's gyroscope
    Gyroscope
    A gyroscope is a device for measuring or maintaining orientation, based on the principles of angular momentum. In essence, a mechanical gyroscope is a spinning wheel or disk whose axle is free to take any orientation...

    was recovered from the wreckage and found to be caged so it was suggested that the automatic pilot might have been engaged inadvertently at a height of about 400 ft (120 m) causing the aircraft to descend into the sea. Engagement could have occurred when the co-pilot intended to select fuel cross-feed off after takeoff. The investigation panel considered inadvertent engagement of the automatic pilot to be the most likely explanation of the accident.

  • Bird strike
    Bird strike
    A bird strike—sometimes called birdstrike, avian ingestion , bird hit, or BASH —is a collision between an airborne animal and a man-made vehicle, especially aircraft...

     - A fortnight after the accident the mutilated body of a large bird was found on Seven-Mile Beach. It was considered the bird, which had a wingspan of about 6 ft (1.8 m), may have struck the aircraft cockpit, distracting or incapacitating the pilots. Alternatively, the bird could have struck the aircraft's pitot tube
    Pitot tube
    A pitot tube is a pressure measurement instrument used to measure fluid flow velocity. The pitot tube was invented by the French engineer Henri Pitot Ulo in the early 18th century and was modified to its modern form in the mid-19th century by French scientist Henry Darcy...

    , damaging it and causing inaccuracy in the pilots' airspeed indicator.

  • Pilot illness - The panel considered the pilot may have collapsed suddenly.

Inquiry

On 24 April 1946 the Minister for Civil Aviation, Arthur Drakeford
Arthur Drakeford
Arthur Samuel Drakeford was an Australian politician and was the minister responsible for the Royal Australian Air Force during World War II...

, appointed Mr Justice Simpson
William Simpson (judge)
William Ballantyne Simpson was an Australian soldier, barrister, Army officer, administrator and Supreme Court judge.-Early life:...

 of the Supreme Court of the Australian Capital Territory
Supreme Court of the Australian Capital Territory
The Supreme Court of the Australian Capital Territory is the superior court for the ACT. It has unlimited jurisdiction within the territory in civil matters , and hears the most serious criminal matters...

 to conduct an inquiry into the accident. Counsel assisting the inquiry was to be Henry Winneke
Henry Winneke
Sir Henry Arthur Winneke AC, KCMG, KCVO, OBE, KStJ, QC was a Chief Justice of the Supreme Court of Victoria and Governor of Victoria.- Early life and career :...

.

Justice Simpson examined the evidence in detail, including the evidence put forward in support of the 3 most likely causes identified by the investigation panel. He eventually found there was insufficient evidence to consider any of the theories proved. He said he was satisfied the accident was not caused by failure of any part of the aircraft's structure, its engines or its controls; or failure to remove any of the flight-control clamps prior to takeoff.

Justice Simpson's report of the findings of his inquiry was made public by the Minister on 11 June 1946.

Automatic pilot

John Watkins, Chairman of the investigation panel, told the Inquiry the only evidence supporting the theory that inadvertent engagement of the autopilot caused the accident was that the gyroscope was recovered from the wreckage and it was still caged. If the autopilot had been engaged at a height of about 400 feet it could explain the swift descent into the sea.

The Flight Superintendent of Australian National Airways, Captain P.T.L. Taylor, told the Inquiry he did not believe the accident could have been caused by inadvertent engagement of the autopilot. He said if that happened, the pilot could dis-engage the autopilot before losing 50 ft (15 m) in altitude.

The Chief Technical Adviser of Australian National Airways, Thomas Lawrence, told the Inquiry he did not think there was any evidence to indicate the aircraft's autopilot was engaged at the time of the accident. He thought the crash was the result of a combination of factors.

John Watkins said that in his report to the Director-General he had made recommendations and they were already being actioned. His recommendations included:
  1. operation of the autopilot lever on DC-3 aircraft should be made distinctive from operation of any other lever in the cockpit.
  2. instructions should be issued impressing on pilots that gyroscopes should be un-caged prior to takeoff.

Bird-strike

Michael Sharland, honorary ornithologist to the Tasmanian Museum, told the Inquiry he had been shown the mutilated remains of a dead bird and had identified it as a gannet
Gannet
Gannets are seabirds comprising the genus Morus, in the family Sulidae, closely related to the boobies.The gannets are large black and white birds with yellow heads. They have long pointed wings and long bills. Northern gannets are the largest seabirds in the North Atlantic, with a wingspan of up...

, a fishing bird known to dive on its prey from heights from 50 ft to 500 ft. He was unable to say how the bird had died but said its injuries suggested it had been in a collision with a heavy, fast-moving body.

Captain P.T.L. Taylor said he thought a bird-strike on the aircraft's pitot tubes could have caused the crash.

Justice Simpson rejected the bird-strike theory, saying the descent of the aircraft was caused by forward-movement of the control column in the cockpit. He was unable to state what caused this movement of the control column.

Medical

The inquiry discovered that the chief-pilot of the aircraft, Captain Thomas Spence, was diabetic and had been discharged from the RAAF in September 1941 as medically unfit. In early 1942 he applied for a commercial pilot licence but did not declare his diabetes. In a medical examination for the purpose of obtaining the licence, and at all subsequent examinations, Spence had shown no sign of diabetes. A specialist in diabetes told the Inquiry it was almost impossible to detect diabetes in a person who wished to withhold it.

The inquiry also received evidence that a friend had asked Spence about his diabetes in relation to his employment as a pilot. Spence had asked his friend to keep it quiet so his employment would not be jeopardised.

The senior route captain for Australian National Airways, Captain Douglas Way, told the inquiry he was unaware Spence was treating himself with insulin
Insulin
Insulin is a hormone central to regulating carbohydrate and fat metabolism in the body. Insulin causes cells in the liver, muscle, and fat tissue to take up glucose from the blood, storing it as glycogen in the liver and muscle....

. Captain Way said he knew Spence had been discharged from the RAAF as medically unfit but Spence had told him it was a minor complaint discovered when he was in Canada and when he returned to Australia he found himself cured.

At a medical examination in October 1943 for renewal of his commercial pilot licence Spence told the examiner he had been in hospital with influenza and a carbuncle. The examiner did not inquire further on the matter. Investigations with Brisbane
Brisbane
Brisbane is the capital and most populous city in the Australian state of Queensland and the third most populous city in Australia. Brisbane's metropolitan area has a population of over 2 million, and the South East Queensland urban conurbation, centred around Brisbane, encompasses a population of...

 Hospital for the purpose of informing Justice Simpson revealed that Spence's hospitalisation was for diabetic pre-coma
Coma
In medicine, a coma is a state of unconsciousness, lasting more than 6 hours in which a person cannot be awakened, fails to respond normally to painful stimuli, light or sound, lacks a normal sleep-wake cycle and does not initiate voluntary actions. A person in a state of coma is described as...

. Justice Simpson agreed that Spence had misled many people.

Spence was scheduled to have a medical examination on 11 March and it was considered plausible that he may have taken extra insulin in order to prepare himself for the examination. An overdose of insulin, or irregular doses, can distort the senses and cause the muscles to be unco-ordinated.

Justice Simpson was critical of the Director-General's investigation panel for considering 25 possible causes of the accident but failing to consider that the Department's negligence in licensing a diabetic pilot might have been the root cause of the accident.

After the inquiry had received all available information related to Spence's diabetes, Justice Simpson said the insulin reaction of the pilot might have had a considerable bearing on the accident. Counsel assisting the Inquiry, Henry Winneke, advocated that the cause of the accident was Spence's diabetes.

In Justice Simpson's report to the Governor-General
Governor-General of Australia
The Governor-General of the Commonwealth of Australia is the representative in Australia at federal/national level of the Australian monarch . He or she exercises the supreme executive power of the Commonwealth...

 he wrote that he could see much to support the theory that the most likely cause was Spence's actions in the cockpit while he was adversely affected by insulin. However, in his report he didn't determine that the accident had been caused by Spence's medical condition because there was insufficient evidence to completely prove the theory.

Irregularities

During the court of inquiry Justice Simpson became aware of four irregularities and listed them in his report.
  1. When Thomas Spence had applied for a commercial pilot licence the RAAF Director-General of Medical Services had been acting as assessor for the Department of Civil Aviation. The Director-General had neglected to check Spence's RAAF medical history.
  2. A medical examiner had failed to check Spence's statement that his recent hospitalisation was due to influenza. The truth was that Spence had been suffering a serious diabetic condition.
  3. VH-AET was approved to carry 24 persons. On 10 March 1946 the aircraft took off with 25 persons on board - a full complement of 21 passengers, an air hostess and 3 pilots instead of the usual 2.
  4. No flare path had been lit to illuminate the runway for takeoff and any unexpected return to the aerodrome for landing.

Recommendations

Justice Simpson made five recommendations:
  1. The practice of allowing pilots under instruction to gain experience in the cockpit of aircraft carrying passengers should be reviewed.
  2. The levers that actuate the automatic pilot and the fuel cross-feed should be modified so they have a different appearance.
  3. A regulation should be made to prohibit taking off at night without a flare path or other runway lighting system; and it should be compulsory for the flare path to remain lit until there is no longer a possibility the aircraft might return to the airport to land.
  4. Ground engineers completing daily inspections should keep copies of their inspection records.
  5. Medical examinations for issue or renewal of pilot licences should be made by doctors chosen, and paid for, by the Department of Civil Aviation.

Coronial inquest

The Tasmania
Tasmania
Tasmania is an Australian island and state. It is south of the continent, separated by Bass Strait. The state includes the island of Tasmania—the 26th largest island in the world—and the surrounding islands. The state has a population of 507,626 , of whom almost half reside in the greater Hobart...

 Coroner
Coroner
A coroner is a government official who* Investigates human deaths* Determines cause of death* Issues death certificates* Maintains death records* Responds to deaths in mass disasters* Identifies unknown dead* Other functions depending on local laws...

, Mr Sorell, investigated the deaths of the 21 people whose bodies had been recovered. He determined that the causes of their deaths were multiple fractures and injuries but he was unable to say how or in what manner they met their deaths.

The aircraft

The aircraft was constructed in 1942 as a Douglas C-47-DL transport aircraft with a Douglas serial number 6013. It was assigned the US military serial number
United States military aircraft serials
In the United States, all military aircraft display a serial number to identify individual aircraft. Because these numbers are located on the aircraft tail, they are sometimes referred to unofficially as "tail numbers"...

 41-18652 and in 1943 was delivered to the US Army Air Force in Brisbane
Brisbane
Brisbane is the capital and most populous city in the Australian state of Queensland and the third most populous city in Australia. Brisbane's metropolitan area has a population of over 2 million, and the South East Queensland urban conurbation, centred around Brisbane, encompasses a population of...

. In November 1944, it was sold to the Commonwealth of Australia. Twelve C-47s were purchased by the Commonwealth of Australia and hired out under charter to aviation companies, six to Australian National Airways
Australian National Airways
Australian National Airways was Australia's predominant carrier from the mid-1930s to the early 1950s.-The Holyman Airways Period:On 19 March 1932 Flinders Island Airways began a regular aerial service using the Desoutter Mk.II VH-UEE Miss Launceston between Launceston, Tasmania and Flinders...

.

The aircraft was registered VH-AET by the Commonwealth and hired out to Australian National Airways on 20 December 1944. Australian National Airways converted it to the civil aircraft configuration about a year before the crash. VH-AET flew for 7,477 hours.

See also

  • 1948 Lutana crash
    1948 Lutana crash
    The 1948 Lutana crash occurred on 2 September 1948 near Nundle, New South Wales, Australia, when the Lutana, a Douglas DC-3 operated by Australian National Airways en route to Sydney from Brisbane, crashed into high terrain due to navigation equipment errors, killing all 13 on board.-Flight:On 2...

     - Douglas DC-3 operated by ANA
  • 1949 MacRobertson Miller Aviation DC-3 crash
    1949 MacRobertson Miller Aviation DC-3 crash
    On 2 July 1949 a Douglas DC-3 aircraft departed from Perth, Western Australia for a night flight of 441 nautical miles to Carnarvon. The aircraft climbed to a height of about 500 feet and then plunged almost vertically to the ground, killing all 18 people on board. It crashed about a...

     - Accident in Perth, Western Australia
  • List of disasters in Australia by death toll
  • List of accidents and incidents involving commercial aircraft
  • List of accidents and incidents involving airliners by location
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