2000 Australia Beechcraft King Air crash
Encyclopedia
Sierra Kilo Charlie was the call sign
Call sign
In broadcasting and radio communications, a call sign is a unique designation for a transmitting station. In North America they are used as names for broadcasting stations...

 for chartered Beechcraft 200 Super King Air
Beechcraft Super King Air
The Beechcraft Super King Air family is part of a line of twin-turboprop aircraft produced by the Beech Aircraft Corporation . The King Air line comprises a number of model series that fall into two families: the Model 90 series, Model 100 series , Model 200 series and Model 300 series...

 which, on 4 September 2000, crashed near Mount Isa, Queensland
Queensland
Queensland is a state of Australia, occupying the north-eastern section of the mainland continent. It is bordered by the Northern Territory, South Australia and New South Wales to the west, south-west and south respectively. To the east, Queensland is bordered by the Coral Sea and Pacific Ocean...

, 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...

. The flight plan of the aircraft called for the pilot to fly between Perth
Perth, Western Australia
Perth is the capital and largest city of the Australian state of Western Australia and the fourth most populous city in Australia. The Perth metropolitan area has an estimated population of almost 1,700,000....

, Western Australia
Western Australia
Western Australia is a state of Australia, occupying the entire western third of the Australian continent. It is bounded by the Indian Ocean to the north and west, the Great Australian Bight and Indian Ocean to the south, the Northern Territory to the north-east and South Australia to the south-east...

, and the mining town of Leonora
Leonora, Western Australia
Leonora is a town in the Goldfields-Esperance region of Western Australia, located northeast of the state capital, Perth, and north of the city of Kalgoorlie. At the 2006 census, Leonora had a population of 401, about a third of whom are of Aboriginal descent. The area is extremely arid, with a...

, Western Australia. During the flight, the aircraft climbed above its assigned altitude. When air traffic control
Air traffic control
Air traffic control is a service provided by ground-based controllers who direct aircraft on the ground and in the air. The primary purpose of ATC systems worldwide is to separate aircraft to prevent collisions, to organize and expedite the flow of traffic, and to provide information and other...

 (ATC) contacted the pilot, the pilot's speech had become significantly impaired and he was unable to respond to instructions. Three aircraft intercepted the Beechcraft but were unable to make radio contact. The aircraft continued flying on a straight heading for five hours before running out of fuel and crashing near Mount Isa, Queensland
Queensland
Queensland is a state of Australia, occupying the north-eastern section of the mainland continent. It is bordered by the Northern Territory, South Australia and New South Wales to the west, south-west and south respectively. To the east, Queensland is bordered by the Coral Sea and Pacific Ocean...

. The incident became known in the media as the "Ghost Flight".

A subsequent investigation concluded the pilot and the passengers had become incapacitated and had been suffering from hypoxia
Hypoxia (medical)
Hypoxia, or hypoxiation, is a pathological condition in which the body as a whole or a region of the body is deprived of adequate oxygen supply. Variations in arterial oxygen concentrations can be part of the normal physiology, for example, during strenuous physical exercise...

, a lack of oxygen to the body, meaning the pilot would have been unable to operate the aircraft. Towards the end of the flight, the left engine began to be starved of fuel and the aircraft impacted with the ground. The accident report said due to the damage to the aircraft upon impact with the ground, investigators were unable to conclude if any of the eight aboard used the oxygen system. The final report, issued by the Australian Transport Safety Bureau
Australian Transport Safety Bureau
The Australian Transport Safety Bureau is Australia’s national transport safety investigator. The ATSB is the federal government body responsible for investigating transport-related accidents and incidents within Australia. It covers air, sea and rail travel. The Australian Transport Safety...

 (ATSB) did not come to a conclusion as to what caused the occupants to become incapacitated. A number of safety recommendations were made following the accident.

Background

The aircraft involved in the accident was a Beechcraft 200 Super King Air
Beechcraft Super King Air
The Beechcraft Super King Air family is part of a line of twin-turboprop aircraft produced by the Beech Aircraft Corporation . The King Air line comprises a number of model series that fall into two families: the Model 90 series, Model 100 series , Model 200 series and Model 300 series...

, registration
Aircraft registration
An aircraft registration is a unique alphanumeric string that identifies a civil aircraft, in similar fashion to a licence plate on an automobile...

 VH-SKC, serial number
Serial number
A serial number is a unique number assigned for identification which varies from its successor or predecessor by a fixed discrete integer value...

 BB-47, manufactured in 1975. The aircraft had been in service for a total for 18,771 hours before the accident. The amount of air passed into the cabin is controlled by bleed air
Bleed air
Bleed air in gas turbine engines is compressed air taken from within the engine, after the compressor stage and before the fuel is injected in the burners. While in theory bleed air could be drawn in any gas turbine engine, its usage is generally restricted to jet engines used in aircraft...

 valves on the engines. The positions of the bleed air valves can be altered on the flight deck. According to the accident report, "The aircraft was not fitted with a high cabin altitude aural warning device, nor was it required to be." The aircraft was fitted with an emergency oxygen system
Emergency oxygen system
Aircraft emergency oxygen systems are emergency equipment fitted to commercial aircraft, intended for use when the cabin pressurisation system has failed and the level of oxygen in the cabin atmosphere drops below a safe level...

—an oxygen tank
Oxygen tank
An oxygen tank is a storage vessel for oxygen, which is either held under pressure in gas cylinders or as liquid oxygen in a cryogenic storage tank.Oxygen tanks are used to store gas for:* industrial processes including the manufacture of steel and monel...

 which could supply oxygen
Oxygen
Oxygen is the element with atomic number 8 and represented by the symbol O. Its name derives from the Greek roots ὀξύς and -γενής , because at the time of naming, it was mistakenly thought that all acids required oxygen in their composition...

 to the crew (through two masks located in the cockpit) and passengers (through masks which would drop down from the ceiling of the cabin).

Accident investigators concluded the aircraft was airworthy at the time the accident occurred, and a pilot who had flown the aircraft several hours before the accident flight took off said the aircraft functioned normally. "The maintenance release was current and an examination of the aircraft’s maintenance records found no recurring maintenance problems that may have been factors in the accident," the accident report stated.

Accident

On 4 September 2000, the aircraft chartered by mining company Sons of Gwalia
Sons of Gwalia
Sons of Gwalia was a Western Australian mining company which mined gold, tantalum, spodumene, lithium and tin.Sons of Gwalia was Australia's third-largest gold producer and also controlled more than half the world's production of tantalum, before entering administration in August 2004 following a...

, departed Perth
Perth, Western Australia
Perth is the capital and largest city of the Australian state of Western Australia and the fourth most populous city in Australia. The Perth metropolitan area has an estimated population of almost 1,700,000....

, Western Australia
Western Australia
Western Australia is a state of Australia, occupying the entire western third of the Australian continent. It is bounded by the Indian Ocean to the north and west, the Great Australian Bight and Indian Ocean to the south, the Northern Territory to the north-east and South Australia to the south-east...

, for the mining town of Leonora
Leonora, Western Australia
Leonora is a town in the Goldfields-Esperance region of Western Australia, located northeast of the state capital, Perth, and north of the city of Kalgoorlie. At the 2006 census, Leonora had a population of 401, about a third of whom are of Aboriginal descent. The area is extremely arid, with a...

, Western Australia, transporting seven workers to Gwalia Gold Mine
Gwalia Gold Mine
The Gwalia Gold Mine is located at Gwalia, a few kilometres south of Leonora, Western Australia. It was originally established by Welsh miners in the late 19th century and Herbert Hoover, the later President of the United States, served as the mine manager in its early days from May to November...

. The aircraft took off
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...

 from Perth at 1009 Coordinated Universal Time
Coordinated Universal Time
Coordinated Universal Time is the primary time standard by which the world regulates clocks and time. It is one of several closely related successors to Greenwich Mean Time. Computer servers, online services and other entities that rely on having a universally accepted time use UTC for that purpose...

 (UTC), and one minute later was cleared by ATC to climb to FL
Flight level
A Flight Level is a standard nominal altitude of an aircraft, in hundreds of feet. This altitude is calculated from the International standard pressure datum of 1013.25 hPa , the average sea-level pressure, and therefore is not necessarily the same as the aircraft's true altitude either...

130 (13000 feet (3,962.4 m)). Five minutes later, at 1015, the aircraft was cleared to ascend to its cruising altitude of FL250 (25000 feet (7,620 m)); the pilot was told to ascend to FL160 by the time it was 36 nmi (66.7 km) from Perth. The pilot acknowledged this transmission.

Five minutes later, at 1020, as the aircraft passed through FL156 (15600 feet (4,754.9 m)) it was cleared to waypoint
Waypoint
A waypoint is a reference point in physical space used for purposes of navigation.-Concept:Waypoints are sets of coordinates that identify a point in physical space. Coordinates used can vary depending on the application. For terrestrial navigation these coordinates can include longitude and...

 DEBRA; the pilot acknowledged this. At approximately 1033 the aircraft ascended through FL256 (25600 feet (7,802.9 m)) and ATC requested the pilot to confirm the altitude of the aircraft. “Sierra Kilo Charlie–um–standby," the pilot said. This was the final spoken transmission from the aircraft, and the altitude of the aircraft continued to increase. According to the accident report, transmissions from the aircraft thereafter were only open-microphone transmissions, sounds of what is believed to be standard background noise produced by the engines, a person breathing, "one unintelligible syllable" and "two chime-like tones, similar to those generated by electronic devices." ATC attempted to regain contact with the aircraft as the transmissions occurred. "Sierra Kilo Charlie Sierra Kilo Charlie Melbourne Centre if receiving this transmission squawk ident" the controller in contact with the aircraft said at 1040. At 1041, the controller asked again, "Sierra Kilo Charlie only receiving open mike from you. Would you contact me on one two five decimal two."

The aircraft continued to ascend and left radar coverage at 1102, climbing through FL325 (32500 feet (9,906 m)). Thirty-one minutes later, Australian Search and Rescue contacted a business jet to request the aircraft fly near the Beechcraft to observe the situation aboard. The flight crew of the jet said the Beechcraft had levelled off at FL343 (34300 feet (10,454.6 m)), and there was no movement on the flight deck or in the cabin. They added the conditions made it difficult to make observations of the situation of the Beechcraft.

Two other aircraft were then told to intercept and monitor the Beechcraft; they sighted it in the Northern Territory
Northern Territory
The Northern Territory is a federal territory of Australia, occupying much of the centre of the mainland continent, as well as the central northern regions...

, northwest of Alice Springs. The flight crews of the aircraft reported the Beechcraft was making a steady descent. Both aircraft followed the Beechcraft during the descent. The airspeed
Airspeed
Airspeed is the speed of an aircraft relative to the air. Among the common conventions for qualifying airspeed are: indicated airspeed , calibrated airspeed , true airspeed , equivalent airspeed and density airspeed....

 of the Beechcraft increased during the descent. "Although its external lights were on, nothing could be seen inside the cabin" the accident report stated. "The crews of the chase aircraft attempted to contact the pilot of the Beechcraft by radio but they did not receive a response." At 1510, the aircraft turned left through 90 degrees as it descended through FL50 (5000 feet (1,524 m)). The aircraft impacted with the ground near Mount Isa, Queensland. Upon impact the aircraft broke up; all seven passengers and the pilot were killed.

Investigation

The accident was investigated by the Australian Transport Safety Bureau
Australian Transport Safety Bureau
The Australian Transport Safety Bureau is Australia’s national transport safety investigator. The ATSB is the federal government body responsible for investigating transport-related accidents and incidents within Australia. It covers air, sea and rail travel. The Australian Transport Safety...

 (ATSB), a federal body responsible for investigating transportation accidents in Australia. The final accident report was published in March 2001. The report was unable to make a definitive conclusion as to the cause of the crash.

The report found all those aboard the aircraft, including the pilot, had likely become incapacitated and begun suffering from hypoxia
Hypoxia (medical)
Hypoxia, or hypoxiation, is a pathological condition in which the body as a whole or a region of the body is deprived of adequate oxygen supply. Variations in arterial oxygen concentrations can be part of the normal physiology, for example, during strenuous physical exercise...

. Hypoxia is a lack of oxygen to body tissues and organs including the brain, heart and lungs, which can occur if an aircraft flying at high altitude becomes depressurized. When affected by hypoxia, a person may initially lose judgement and suffer impaired vision. "Simple tasks become extraordinarily difficult and performance fails," a report on hypoxia states. "As hypoxia continues, you become semiconscious. After you lose consciousness entirely, you have only minutes to live, depending on the altitude."

The accident report stated, "After the aircraft climbed above the assigned altitude of FL250, the speech and breathing patterns of the pilot, evidenced during the radio transmissions, displayed changes consistent with hypoxia." Investigators were, however, unable to conclusively dismiss toxic fumes as the cause. "The incapacitation of the pilot and passengers was probably due to hypobaric hypoxia because of the high cabin altitude and their not receiving supplemental oxygen" the report said, adding, "The reasons for the pilot and passengers not receiving supplemental oxygen [from the oxygen tank aboard the aircraft] could not be determined."

The ATSB found it likely that the autopilot was engaged, and this caused the aircraft to fly on a straight heading; the vertical path of the aircraft indicated climb power had been set before the occupants of the aircraft were incapacitated. "The design of the aircraft systems were such that, with the autopilot engaged, the engines would continue to operate and the aircraft would continue to fly without human input until it was disrupted by other events, such as collision or fuel exhaustion," according to the accident report. It was suggested that, towards to the end of the flight, the fuel tank for the left engine on the aircraft was almost empty. "The near exhaustion of fuel in the left wing tanks may have produced at least one, and probably several, momentary losses of left engine power shortly before all power was lost" the report said. "The aircraft yawed and rolled towards the left engine, as was observed shortly before the aircraft collided with the ground."

The accident report said due to the damage to the aircraft upon impact with the ground, investigators were unable to conclude if any of the eight aboard used the oxygen system. However, the report stated "The absence of a distress radio call, or an attempt to descend the aircraft, and the likelihood that the pilot did not don his oxygen mask, suggested that the pilot was unaware that the aircraft was unpressurised or depressurising." The passengers, the report added, were also likely not wearing their oxygen masks, as there was no noise recorded on the ATC transmissions indicating they were attempting to assist the pilot.

Investigators were not able to determine what caused the depressurisation of the aircraft, but stated likely causes included either an incorrect switch selection due to pilot error
Pilot error
Pilot error is a term used to describe the cause of an accident involving an airworthy aircraft where the pilot is considered to be principally or partially responsible...

 or a mechanical failure in the aircraft pressurization system. The air traffic control recordings suggested it was unlikely a rapid decompression had occurred. "During an explosive or rapid depressurisation of a pressurised aircraft, however, the noise, pressure changes, temperature changes and draughts within the cabin would have alerted the occupants that a substantial failure had occurred," the report added. The document listed the two main factors in the accident as,

Aftermath

The flight deck of the Beechcraft Super King Air has visual warning if cabin altitude is too high. It is likely the pilot of the accident aircraft was suffering from hypoxia and did not notice the visual warning. In the aftermath of an incident in 1999 involving the pilot of a Beechcraft Super King Air suffering hypoxia, the ATSB published Report 199902928 and recommended an aural warning be fitted on the flight deck, in addition to the visual warning, on all Beechcraft Super King Air aircraft. The Civil Aviation Safety Authority
Civil Aviation Safety Authority
The Civil Aviation Safety Authority is the Australian national aviation authority , the government statutory authority responsible for the regulation of civil aviation.-History:...

 (CASA) issued a notice to owners of pressurised aircraft registered in Australia recommending installation of an aural warning, but did not make it mandatory. The notice said, "The benefit to your pilots and passengers lies in the reduction in risk of an uncommanded depressurisation leading to an incident or fatal accident. The benefit is much greater than the cost of purchase and installation of one of these low-cost systems."

When the air traffic controller responsible for the Beechcraft received the open-microphone transmissions, he alerted his supervisor that he was concerned the pilot could be suffering from hypoxia. The controller and his supervisor completed the standard checklist which, at the time, did not include a procedure to follow in the case of incapacitation or hypoxia. In the aftermath of the accident, the checklist was changed to "incorporate procedures to be followed by air traffic controllers, when a controller suspects that a pilot has been affected by hypoxia."

See also

  • Helios 522
  • 1999 South Dakota Learjet crash
    1999 South Dakota Learjet crash
    On October 25, 1999, a chartered Learjet 35 was scheduled to fly from Orlando, Florida to Dallas, Texas. Early in the flight the aircraft, which was cruising at altitude on autopilot, gradually lost cabin pressure. As a result, all on board were incapacitated due to hypoxia— a lack of oxygen...

  • List of notable decompression accidents and incidents
  • Air safety
    Air safety
    Air safety is a term encompassing the theory, investigation and categorization of flight failures, and the prevention of such failures through regulation, education and training. It can also be applied in the context of campaigns that inform the public as to the safety of air travel.-United...

  • 2000 in aviation
    2000 in aviation
    This is a list of aviation-related events from 2000:s-January:* January 30 – Kenya Airways Flight 431 crashes into the Atlantic Ocean, killing 169....

  • 2000 in Australia
    2000 in Australia
    -Incumbents:*Monarch – Elizabeth II*Governor-General – Sir William Deane*Prime Minister – John Howard-Premiers and Chief Ministers:*Premier of New South Wales – Bob Carr*Premier of Queensland – Peter Beattie*Premier of South Australia – John Olsen...

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