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1949 MacRobertson Miller Aviation DC-3 crash

August 18, 2023

On 2 July 1949 a Douglas DC-3 aircraft departed from Perth, Western Australia for a night flight of 441 nautical miles (817 km) to Carnarvon. The aircraft climbed to a height of about 500 feet (150 m) and then spiralled almost vertically to the ground, killing all 18 people on board. It crashed about a mile north of Perth airport and burned for over an hour. At the time, it was the worst civil aviation accident in Western Australia.[Note 1][2][3][4]

MMA DC-3 crash
crash site
Accident
Date2 July 1949
SummaryLoss of control after takeoff
SitePerth, Western Australia
31°55′18″S 115°58′16″E / 31.9216°S 115.9710°E / -31.9216; 115.9710
Aircraft
Aircraft typeDouglas DC-3
RegistrationVH-MME
Flight originPerth, Western Australia
DestinationCarnarvon, Western Australia
Occupants18
Passengers14
Crew4
Fatalities18
Survivors0
External image
Newspaper cover page
External images
Photograph 1 of crash site.
Photograph 2 of crash site.
Newspaper photographs of crash site.

The flight

The aircraft was the airliner Fitzroy, registered VH-MME and operated by MacRobertson Miller Aviation.[Note 2][3][7] On 2 July 1949 it was about to conduct the regular passenger service from Perth to Darwin, Northern Territory which departed about 2 am to allow passengers to connect with the twice-weekly Sydney-London flight operated by Qantas.[8] The first stop was to be Carnarvon in Western Australia.[Note 3] On board were three pilots, an air hostess and 14 passengers.[Note 4] The aircraft took off at 2:14 am in driving rain.[10] Visibility was about 10 miles (16 km).[11] The aircraft climbed unusually quickly after it left the runway. It was observed to climb to a height of about 500 feet (150 m) and then roll and spiral vertically to the ground.[8][12][13]

The aircraft crashed in a clear area between huts at the South Guildford housing camp, a former Army camp where 70 huts were being used to house civilians.[Note 5][15][16][17] As a result of the aircraft diving vertically to the ground, the wreckage was mostly confined within an area that was no larger than 60 feet (18 m) square.[Note 6] The aircraft narrowly missed the surrounding huts with wreckage coming to within 12 feet (4 m) of one hut, and within 5 paces of the front verandah of another. One propeller was found about 210 feet (64 m) from the wreckage.[1][2][3]

An intense fire erupted inside the fuselage. The first fire-fighting equipment to reach the site was the fire tender from the airport, crewed by one fireman only. The fireman[Note 7] laid a foam blanket around the burning wreckage and sprayed foam on the fire.[13] He used all the foam without extinguishing the flames. Two other fire tenders from neighbouring areas arrived to assist. It was 90 minutes before the fire was extinguished.[3][18][19]

After sunrise, police, firemen and undertakers worked for an hour to remove the bodies of the 18 people killed in the accident. All the bodies were burned beyond recognition. Several of the bodies were still sitting in an upright position. The bodies of the 3 pilots in the cockpit were half-buried under a mass of charred newspaper. The aircraft was carrying the Perth daily newspaper to towns in the north-west of the state.[10] Police and two officers from the Department of Civil Aviation sifted through the wreckage in the rain, searching for items to help identify the victims and for clues as to the likely cause of the tragedy.[Note 8][16]

Investigation

The Department of Civil Aviation immediately appointed a panel of two to investigate the accident.[Note 9][20] Examination of the wreckage showed that the flaps and undercarriage were retracted and both engines had been producing high power at the time of the crash. All trim tabs were in typical positions for takeoff and all control cable runs were intact. Nothing was found in the wreckage to indicate any prior defect or failure that might have caused the aircraft to crash or the pilot to lose control. The setting of the automatic pilot could not be determined due to destruction of the forward fuselage.[23] The investigation initially focussed on possible failure to remove one of the flight control chocks, defective flight instruments, misuse of the wing flaps, structural failure of the tailplane, defective elevator control system, misuse of the automatic pilot, and incorrect loading.[24]

Control chocks for the left aileron, one elevator and the rudder were found correctly stowed in the remains of the aircraft's rear fuselage compartment. Searchers were unable to find the chock for the other elevator or the right aileron, either at the crash site or on the ground between the runway and the crash site. On the morning after the accident an MMA apprentice found the missing elevator chock on the tarmac close to where VH-MME was positioned for an engine test run the previous afternoon.[23] The investigators carried out a flight test on a DC-3 to determine what effect, if any, was caused by installing an aileron chock on the elevator. They found there was no effect and the presence of the chock did not prevent the pilot having full control of the elevator.[21]

Staff of the Department of Civil Aviation calculated the most likely position of the centre of gravity on the fatal flight and found it was about 3.3% of Mean Aerodynamic Chord behind the rear limit.[Note 10] They carried out some flight tests in a DC-3 with its centre of gravity 4.7% of MAC behind the rear limit and found there was a loss of longitudinal static stability that made it difficult to trim the aircraft for a constant airspeed but the low-speed flight handling qualities had not deteriorated seriously. They concluded that the incorrect position of the centre of gravity did not adequately explain the accident and there must have been some other cause, possibly highly unusual.[24] The investigation ended without determining the cause.[25][26]

Inquest

In August 1949 the City Coroner, R. P. Rodriguez, conducted an inquest into the deaths of the 18 people on board the aircraft.[12]

A dispatch officer with MacRobertson Miller Aviation[Note 11] observed the aircraft take off normally, then climb to an almost vertical position, roll over and dive vertically towards the ground, twisting as it did so.[12] Written evidence from the aerodrome control officer[Note 12] on duty in the control tower stated that he observed the aircraft turn through 180 degrees as though in a spiral turn or spin.[12]

Some witnesses who lived at the South Guildford housing camp believed one of the aircraft's engines had failed by the time of the crash. The City Coroner was satisfied both engines were operating normally during the takeoff and up until the time of the impact.[11][12]

A medical officer[Note 13] conducted post-mortem examinations of the bodies. He confirmed there was no indication of alcohol in the bodies of any of the pilots. All on board died of multiple injuries before being burned.[12]

A resident of the housing camp who was one of the first witnesses to arrive at the crash scene told the City Coroner she saw the air hostess in the cockpit, standing beside the pilot.[Note 14][12]

The City Coroner was satisfied that the aircraft was airworthy and neither MacRobertson Miller Aviation nor the pilot did anything negligent to cause the fatal crash.[11][12]

Inquiry

On 28 September 1949 the Minister for Civil Aviation, Arthur Drakeford, announced that a court of inquiry would be held to investigate the accident because the investigation by the Department of Civil Aviation had been unable to determine the exact cause. Mr Justice Wolff[Note 15] of the Supreme Court of Western Australia was appointed to chair the inquiry.[25] The inquiry commenced on 12 December 1949.[27]

Observations

The inquiry received evidence from the aerodrome control officer on duty in the control tower at the time of the takeoff.[Note 16] He observed the aircraft climb at a steeper rate than any airline-operated aircraft he had seen previously. When the aircraft was at a height of about 500 feet (150 m) the left wing dropped sharply, as if in a stall. The nose dipped and the aircraft seemed to rotate through 180 degrees before dropping vertically. A ground engineer[Note 17] also saw the aircraft climb abruptly before it nosed over and twisted twice as it dived to the ground.[13]

Aircraft loading

The inquiry heard that on 27 June 1949 the Department of Civil Aviation sent a letter to MacRobertson Miller Aviation advising that the methods used by its operational personnel to check the weight and balance of company aircraft did not conform to the appropriate requirements, and that approved methods must be used in the future. In response, the Operations Manager for MacRobertson Miller Aviation sent specific instructions to pilots on 30 June. On 1 July, the day before the accident, the Operations Manager discussed his instructions with the pilots of the accident flight.[Note 18][28] Staff involved with the loading of aircraft were instructed to use the method of Index Units to check that the centre of gravity of an aircraft was within limits. The employee who loaded the freight and passengers' luggage on the accident flight told the inquiry that after the freight was loaded, a check of the aircraft weight and balance showed that about 80 pounds (36 kg) of freight should be removed. Freight weighing 102 pounds (46 kg) was then removed. However, this employee believed the Load Sheet column labelled Index Units was not completed.[Note 19][8][29]

There were suggestions the aircraft had been incorrectly loaded with 1,400 pounds (640 kg) in the rear baggage locker when it was assumed only 1,100 pounds (500 kg) would be carried there.[28][29] The accuracy of statements regarding 1,400 lb was challenged.[29][30]

Control chocks

The inquiry heard that the first officer had been unable to find all the control chocks normally used to lock the control surfaces on the aircraft while it was parked. There were concerns that one of the aircraft's control chocks might have been left in position instead of being removed before takeoff.[21] The inquiry heard that all chocks were eventually accounted for.[31] There was also a concern that one of the aileron chocks might have been inadvertently inserted in the elevator circuit. Chief Inspector James Harper told the inquiry that he made some test flights in a DC-3 aircraft in a similar configuration to the Fitzroy on the accident flight. One test showed that the DC-3 could be flown satisfactorily even with an aileron chock in the elevator circuit. Harper was satisfied the aircraft did not take off with the elevator locked.[21]

Pilot competency

The pilot in command of the aircraft on the accident flight was Captain William Norman.[Note 20] Captain Cyril Kleinig, an approved checking pilot with MacRobertson Miller Aviation, gave evidence to the inquiry. He had flown with Captain Norman on many occasions and described him as competent.[Note 21][12][33] A pilot who had flown the Fitzroy to Carnarvon and return the day before the accident told the inquiry the aircraft had behaved normally. He also said he had flown with Captain Norman many times and found him to be careful and competent, and more meticulous than most in performing his cockpit drills.[Note 22][31]

Air hostess

Two residents of the housing camp who were among the first to arrive at the crash scene told the inquiry they could see two bodies in the wreckage of the cockpit – a male and a female, both wearing uniform, so they presumed the bodies were those of the pilot and air hostess. One described the female as having fairly long blonde hair.[Note 23][13][31] The superintendent of air navigation and safety in the western region of the Department of Civil Aviation[Note 24] said the bodies of the pilot and first officer were found in their correct seats in the cockpit. Particular attention was paid to the body found closest to the rear of the cabin, a few feet (a metre) forward of the hostess's seat. The body was that of a female.[28] Another witness was an employee of MacRobertson Miller Aviation who raced from the airport to the scene of the crash.[Note 25] He contradicted the evidence that the body of a woman could be seen in the cockpit. He told the inquiry the air hostess had red hair.[29]

Irregularities

The inquiry exposed certain irregularities in MacRobertson Miller Aviation's operations. These irregularities centred on the loading of aircraft, proper completion of Load Sheets, and administrative methods.[34]

Counsels' summaries

The Department of Civil Aviation was represented by Henry Winneke.[Note 26][30] Mr Winneke suggested to the inquiry that the immediate cause of the accident was that the pilot lost flying control of the aircraft. He said the reason for this loss of control was unknown although incorrect loading of the aircraft may have contributed. He acknowledged the excellent work done by the Department's accident investigators in attempting to determine the cause.[34] George Pape,[Note 27] counsel representing MacRobertson Miller Aviation, warned against speculating on what might have caused the crash and urged the court to make an explicit finding that loading of the aircraft was not a possible factor contributing to the cause of the crash.[30]

The inquiry sat for seven days and adjourned on Wednesday 21 December 1949.[30]

Report and findings

The report and findings of the inquiry were not released until 8 March 1950 when the new Minister for Civil Aviation,[Note 28] Thomas White, tabled them in the House of Representatives. The report confirmed that the crash occurred because the aircraft stalled and the pilots were unable to regain control. However, the evidence was not sufficient to allow determination of what caused the stall.[26] The report conceded that over-loading of the aircraft's rear baggage compartment may have contributed to the stall.[37][38]

The inquiry acknowledged that the operator, MacRobertson Miller Aviation, had distributed instructions about aircraft loading to its pilots on 30 June but considered more should have been done. On the night of the accident the pilot in command had not checked the loading calculations performed by the two men responsible for loading the aircraft, as he was required to do, although the inquiry acknowledged there was insufficient evidence to conclude that the pilot in command was responsible for the accident. The inquiry considered the man responsible for loading the rear baggage compartment possessed inadequate knowledge of aircraft loading and had been untruthful.[Note 29] He had invented his story to hide his over-loading of the compartment.[26][37][39][40][41]

The inquiry was critical of the operator and the Department of Civil Aviation.[26] In particular, it was critical of the operator's poor standards of maintenance of aircraft instruments. For this reason, the inquiry recommended the operator's airline licence should be suspended or cancelled. It also considered the Department should have made more checks of the operator's methods and record keeping. The Minister declined to take action against the operator, saying its maintenance record keeping had improved significantly since the accident. He also cited the hardship that would be inflicted on many remote communities in Western Australia if the operator's airline licence were to be suspended or cancelled. The Minister said his Department would be extra vigilant towards the operator but conceded there were limits to what could be done without significant increases in staff numbers.[38][39][42]

The inquiry was also critical of the lack of qualifications and experience of the pilot in command, the late Captain Norman. It said Norman should not have been promoted to captain, and evidence from Captain Kleinig in support of Captain Norman was worthless. It recommended that promotion of a pilot to Captain of an airliner should be at the discretion of the Department of Civil Aviation, and that the Department should take account of all records and reports of tests relating to the applicant.[26][37][39]

The Managing-Director of MacRobertson Miller Aviation, Mr E.C. Gare, rejected claims of incorrect loading on the night of the accident. He also defended Captain Norman, saying he had 3,500 hours flying experience and an unblemished record.[43]

Aircraft

The aircraft was constructed as a Douglas C-47A-20-DL transport aircraft with a Douglas serial number 9350. It was completed in April 1943 and assigned the military serial number 42-23488. It was delivered to the US Army Air Force in Brisbane in May 1943.[9]

In July 1946, it was acquired by MacRobertson Miller Aviation and ferried from the Philippines to Perth, where it was converted from a military C-47 to a civil DC-3 with seating for 21 passengers.[44] It was registered by MacRobertson Miller Aviation in March 1947[Note 30][9] and named Fitzroy.[6]

See also

Notes

  1. ^ In July 1949 Australia's worst civil aviation accident was the 1946 Australian National Airways DC-3 crash in Hobart that killed all 25 occupants. The second-worst was a Lockheed 18 Lodestar that crashed at Coolangatta in March 1949, killing all 21 occupants. Third-worst was shared by two that caused the death of all 18 occupants – the 1938 Kyeema crash east of Melbourne, and the Fitzroy at Perth airport. The crash of the Fitzroy remained the worst in Western Australia until June 1950 when the DC-4 Amana crashed near York, killing all 29 occupants.[1]
  2. ^ MacRobertson Miller Aviation merged with Airlines (WA) in late 1955 and was re-named MacRobertson Miller Airlines. MacRobertson Miller named its aircraft after West Australian rivers.[5][6]
  3. ^ The Perth to Darwin service made intermediate stops at Carnarvon, Port Hedland, Derby and Wyndham.[9]
  4. ^ The Douglas DC-3 is operated by two pilots. On this flight there were two pilots and a supernumerary pilot in the cockpit. The supernumerary, Captain Eric Charles Langford, was travelling as far as Derby to take command of another flight.[2][10]
  5. ^ Formerly Guildford Army Camp.[14] Some sources named the housing camp as Camp No. 22.[15]
  6. ^ One source stated the clear area was 100 feet square.[17] Other sources stated the wreckage of the Fitzroy was mostly concentrated in an area 20 yards (18 m) square.[18]
  7. ^ Fireman Arthur David James Firth said that at least 3 fire tenders would have been necessary to extinguish the fire.[13]
  8. ^ The officers from the Department of Civil Aviation's western region were Robert Walter Ridley and R. K. Pritchard.[16]
  9. ^ The panel consisted of Chief Inspector James Herbert Harper and Accident Investigator James Edward Schofield.[20][21][22]
  10. ^ The position of passengers and cargo was not known precisely. The position of the centre of gravity was most likely to have been between 2.0% and 4.7% of MAC behind the rear limit.[24]
  11. ^ The dispatch officer was Vivian James Dandridge.[12] Another source described him as a ground engineer.[13]
  12. ^ The aerodrome control officer was Ronald David Dyson.[12] Another source named him as Raymond David Dyson.[13]
  13. ^ Alan T. Pearson, district medical officer[12]
  14. ^ The witness was Mrs Gwendoline Gilbert. Her statement that she saw the air hostess standing in the cockpit beside the pilot was at odds with other evidence, including evidence from post-mortem examinations of the bodies.[12]
  15. ^ Albert Wolff was appointed Chief Justice of Western Australia in February 1959. He was knighted in June 1959.
  16. ^ The aerodrome control officer was Raymond David Dyson.[13] Another source named him as Ronald David Dyson.[12]
  17. ^ The ground engineer was Vivian James Dandridge who tested the engines prior to the fatal flight and found them to be operating normally.[13] Another source described him as a dispatch officer.[12]
  18. ^ The Operations Manager was Kenneth Cohen.[28]
  19. ^ Colin Oliver Mason, senior despatch officer for MMA, gave evidence regarding the weighing of passengers and their luggage but said he did not believe it was his responsibility to complete the Load Sheet column labelled Index Units. The employees who loaded the freight and passengers' luggage were Robert Woods and Ronald Butler.[29]
  20. ^ Captain of the aircraft was William Graham Norman, unmarried, aged 27 years.[2] He served in the RAAF until joining MMA in July 1947.[32]
  21. ^ The approved checking pilot was Cyril Nathaniel Kleinig, Assistant managing director of MMA.[12][33]
  22. ^ The witness who had flown the Fitzroy the day before the accident was Arthur Edward Budd. Budd had flown as First Officer with Captain Norman on many occasions.[31]
  23. ^ The witnesses were George Robert Forbes and Harry John Jones. Their evidence regarding the air hostess in the cockpit was at odds with other evidence presented at the inquiry, including evidence from post-mortem examinations of the bodies.[13][31]
  24. ^ Mr Eorl Huntley Fry.[12]
  25. ^ The witness was Colin Oliver Mason, senior despatch officer for MMA.[29]
  26. ^ Sir Henry Arthur Winneke was knighted in 1957 and later became Chief Justice of the Supreme Court of Victoria (1964) and Governor of Victoria (1974.)
  27. ^ George Augustus Pape, later Sir George, became a Justice in the Supreme Court of Victoria in 1957 and served until 1975.[35]
  28. ^ The Australian labour government, in which Arthur Drakeford was Minister for Civil Aviation, was defeated at the federal election on 10 December 1949. A coalition government of conservative parties was formed with former AFC pilot and RAAF officer Thomas White as the Minister for Civil Aviation.[36] See Fourth Menzies Ministry.
  29. ^ Ronald Frederick Butler[29]
  30. ^ The aircraft was registered VH-AXM in March 1947. ICAO subsequently prohibited use of registrations beginning AX so the aircraft was re-registered VH-BXM in November 1948. It was re-registered VH-MME in December 1948.[9]

References

  1. ^ a b "Earlier Air Disasters In Australia" The West Australian – 27 June 1950, p.1 (National Library of Australia) Retrieved 11 November 2011
  2. ^ a b c d "18 Killed In WA's Worst Plane Crash" The Argus – 4 July 1949, p.3 (National Library of Australia) Retrieved 11 November 2011
  3. ^ a b c d "All Killed When Airliner Crashes At Guildford" The Sunday Times – 3 July 1949, p.1 (National Library of Australia) Retrieved 11 November 2011
  4. ^ "Air Safety Record" The West Australian – 4 July 1949, p.4 (National Library of Australia) Retrieved 11 November 2011
  5. ^ "£2 mil. air co. formed" The Argus – 24 June 1955, p.16 (National Library of Australia) Retrieved 11 November 2011
  6. ^ a b RAAF Association of WA. Retrieved 14 September 2016
  7. ^ "Guildford Disaster" The West Australian – 4 July 1949, p.2 (National Library of Australia) Retrieved 11 November 2011
  8. ^ a b c Job 1992, p. 113
  9. ^ a b c d Aussie Airliners Retrieved 11 November 2011
  10. ^ a b c "18 Incinerated In W.A. Plane Crash" The Mail – 2 July 1949, p.1 (National Library of Australia) Retrieved 11 November 2011
  11. ^ a b c "No Negligence In Plane Crash" The West Australian – 26 August 1949, p.12 (National Library of Australia) Retrieved 11 November 2011
  12. ^ a b c d e f g h i j k l m n o p q "Evidence At Guildford Air Crash Inquest" The West Australian – 23 August 1949, p.9 (National Library of Australia) Retrieved 11 November 2011
  13. ^ a b c d e f g h i j "Ill-Fated DC3 Turned Over Backwards" The West Australian – 13 December 1949, p.8 (National Library of Australia) Retrieved 11 November 2011
  14. ^ Ozatwar "Peter Dunn's Australia @ War" Retrieved 11 November 2011
  15. ^ a b "Brief Story Of Crash" The Geraldton Guardian – 2 July 1949, p.3 (National Library of Australia) Retrieved 11 November 2011
  16. ^ a b c "Tangled Wreckage Of DC3 At Guildford" The Sunday Times – 3 July 1949, p.2 (1) (National Library of Australia) Retrieved 11 November 2011
  17. ^ a b "Airliner In Flames After Crash" The Sunday Herald – 3 July, p.3 (National Library of Australia) Retrieved 11 November 2011
  18. ^ a b "Cause Of Air Crash Not Known" The West Australian – 4 July 1949, p.3 (National Library of Australia) Retrieved 11 November 2011
  19. ^ "Tender Driver Fought Fire" The Sunday Times – 3 July 1949, p.2 (2) (National Library of Australia) Retrieved 11 November 2011
  20. ^ a b "Plane Crash Report Ready Tomorrow" The Argus – 5 July 1949, p.7 (National Library of Australia) Retrieved 11 November 2011
  21. ^ a b c d "Alleged Ordeal In Airliner" The West Australian – 20 December 1949, p.7 (National Library of Australia) Retrieved 11 November 2011
  22. ^ "Water In Tanks Worry To RAAF" The Courier Mail – 16 February 1951, p.3 (National Library of Australia) Retrieved 11 November 2011
  23. ^ a b Job 1992, p. 114
  24. ^ a b c Job 1992, p. 115
  25. ^ a b "Air Tragedy Inquiry" The West Australian – 29 September 1949, p.16 (National Library of Australia) Retrieved 11 November 2011
  26. ^ a b c d e Job 1992, p. 116
  27. ^ "Air Disaster Inquiry" The West Australian – 5 October 1949, p.24 (National Library of Australia) Retrieved 11 November 2011
  28. ^ a b c d "Loading Discussed Before Crash" The West Australian – 16 December 1949, p.12 (National Library of Australia) Retrieved 11 November 2011
  29. ^ a b c d e f g "Load Distribution In Crashed DC3" The West Australian – 15 December 1949, p.8 (National Library of Australia) Retrieved 11 November 2011
  30. ^ a b c d "Counsel's Submissions At Air Crash Inquiry" The West Australian – 22 December 1949, p.11 (National Library of Australia) Retrieved 11 November 2011
  31. ^ a b c d e "Chock Found On Tarmac After DC3 Crash" The West Australian – 14 December 1949, p.13 (National Library of Australia) Retrieved 11 November 2011
  32. ^ "Died In Crash" The Sunday Times – 3 July 1949, p.2(3) (National Library of Australia) Retrieved 11 November 2011
  33. ^ a b "Earlier Behaviour Of Crashed DC3" The West Australian – 17 December 1949, p.4 (National Library of Australia) Retrieved 11 November 2011
  34. ^ a b "Irregularities Exposed In Crash Inquiry" The West Australian – 21 December 1949, p.14 (National Library of Australia) Retrieved 11 November 2011
  35. ^ Job 1992, p. 131
  36. ^ "New Menzies Ministry Announced" The Canberra Times – 19 December 1949 (National Library of Australia) Retrieved 8 May 2012
  37. ^ a b c "Critical Report On Air Crash" The West Australian – 9 March 1950 (National Library of Australia) Retrieved 5 March 2012
  38. ^ a b "Drastic Penalty For W.A. Airline Avoided" The Canberra Times – 9 March 1950, p.4 (National Library of Australia) Retrieved 5 March 2012
  39. ^ a b c "Air-Crash Inquiry Findings" The West Australian – 9 March 1950, p.4 (National Library of Australia) Retrieved 5 March 2012
  40. ^ "Air Crash Report" The Sydney Morning Herald – 9 March 1950, p.5 (National Library of Australia) Retrieved 5 March 2012
  41. ^ "Air firm was warned, days before crash" The Argus – 9 March 1950, p.8 (National Library of Australia) Retrieved 5 March 2012
  42. ^ Job 1992, p. 117
  43. ^ "Comment By M.M.A." The West Australian – 9 March 1950, p.4 (National Library of Australia) Retrieved 5 March 2012
  44. ^ "Airport Round-Up" The West Australian – 15 March 1947, p.14 (National Library of Australia) Retrieved 11 November 2011

Bibliography

  • Job, Macarthur (1992). Air Crash Vol. 2, Chapter 8. Aerospace Publications Pty. Ltd. Fyshwick, Australia. pp. 200. ISBN 1-875671-01-3

External links

  • Aviation Safety Network

August 18, 2023
1949, macrobertson, miller, aviation, crash, july, 1949, douglas, aircraft, departed, from, perth, western, australia, night, flight, nautical, miles, carnarvon, aircraft, climbed, height, about, feet, then, spiralled, almost, vertically, ground, killing, peop. On 2 July 1949 a Douglas DC 3 aircraft departed from Perth Western Australia for a night flight of 441 nautical miles 817 km to Carnarvon The aircraft climbed to a height of about 500 feet 150 m and then spiralled almost vertically to the ground killing all 18 people on board It crashed about a mile north of Perth airport and burned for over an hour At the time it was the worst civil aviation accident in Western Australia Note 1 2 3 4 MMA DC 3 crashcrash siteAccidentDate2 July 1949SummaryLoss of control after takeoffSitePerth Western Australia 31 55 18 S 115 58 16 E 31 9216 S 115 9710 E 31 9216 115 9710AircraftAircraft typeDouglas DC 3RegistrationVH MMEFlight originPerth Western AustraliaDestinationCarnarvon Western AustraliaOccupants18Passengers14Crew4Fatalities18Survivors0External imageNewspaper cover pageExternal imagesPhotograph 1 of crash site Photograph 2 of crash site Newspaper photographs of crash site Contents 1 The flight 2 Investigation 3 Inquest 4 Inquiry 4 1 Observations 4 2 Aircraft loading 4 3 Control chocks 4 4 Pilot competency 4 5 Air hostess 4 6 Irregularities 4 7 Counsels summaries 4 8 Report and findings 5 Aircraft 6 See also 7 Notes 8 References 9 Bibliography 10 External linksThe flight EditThe aircraft was the airliner Fitzroy registered VH MME and operated by MacRobertson Miller Aviation Note 2 3 7 On 2 July 1949 it was about to conduct the regular passenger service from Perth to Darwin Northern Territory which departed about 2 am to allow passengers to connect with the twice weekly Sydney London flight operated by Qantas 8 The first stop was to be Carnarvon in Western Australia Note 3 On board were three pilots an air hostess and 14 passengers Note 4 The aircraft took off at 2 14 am in driving rain 10 Visibility was about 10 miles 16 km 11 The aircraft climbed unusually quickly after it left the runway It was observed to climb to a height of about 500 feet 150 m and then roll and spiral vertically to the ground 8 12 13 The aircraft crashed in a clear area between huts at the South Guildford housing camp a former Army camp where 70 huts were being used to house civilians Note 5 15 16 17 As a result of the aircraft diving vertically to the ground the wreckage was mostly confined within an area that was no larger than 60 feet 18 m square Note 6 The aircraft narrowly missed the surrounding huts with wreckage coming to within 12 feet 4 m of one hut and within 5 paces of the front verandah of another One propeller was found about 210 feet 64 m from the wreckage 1 2 3 An intense fire erupted inside the fuselage The first fire fighting equipment to reach the site was the fire tender from the airport crewed by one fireman only The fireman Note 7 laid a foam blanket around the burning wreckage and sprayed foam on the fire 13 He used all the foam without extinguishing the flames Two other fire tenders from neighbouring areas arrived to assist It was 90 minutes before the fire was extinguished 3 18 19 After sunrise police firemen and undertakers worked for an hour to remove the bodies of the 18 people killed in the accident All the bodies were burned beyond recognition Several of the bodies were still sitting in an upright position The bodies of the 3 pilots in the cockpit were half buried under a mass of charred newspaper The aircraft was carrying the Perth daily newspaper to towns in the north west of the state 10 Police and two officers from the Department of Civil Aviation sifted through the wreckage in the rain searching for items to help identify the victims and for clues as to the likely cause of the tragedy Note 8 16 Investigation EditThe Department of Civil Aviation immediately appointed a panel of two to investigate the accident Note 9 20 Examination of the wreckage showed that the flaps and undercarriage were retracted and both engines had been producing high power at the time of the crash All trim tabs were in typical positions for takeoff and all control cable runs were intact Nothing was found in the wreckage to indicate any prior defect or failure that might have caused the aircraft to crash or the pilot to lose control The setting of the automatic pilot could not be determined due to destruction of the forward fuselage 23 The investigation initially focussed on possible failure to remove one of the flight control chocks defective flight instruments misuse of the wing flaps structural failure of the tailplane defective elevator control system misuse of the automatic pilot and incorrect loading 24 Control chocks for the left aileron one elevator and the rudder were found correctly stowed in the remains of the aircraft s rear fuselage compartment Searchers were unable to find the chock for the other elevator or the right aileron either at the crash site or on the ground between the runway and the crash site On the morning after the accident an MMA apprentice found the missing elevator chock on the tarmac close to where VH MME was positioned for an engine test run the previous afternoon 23 The investigators carried out a flight test on a DC 3 to determine what effect if any was caused by installing an aileron chock on the elevator They found there was no effect and the presence of the chock did not prevent the pilot having full control of the elevator 21 Staff of the Department of Civil Aviation calculated the most likely position of the centre of gravity on the fatal flight and found it was about 3 3 of Mean Aerodynamic Chord behind the rear limit Note 10 They carried out some flight tests in a DC 3 with its centre of gravity 4 7 of MAC behind the rear limit and found there was a loss of longitudinal static stability that made it difficult to trim the aircraft for a constant airspeed but the low speed flight handling qualities had not deteriorated seriously They concluded that the incorrect position of the centre of gravity did not adequately explain the accident and there must have been some other cause possibly highly unusual 24 The investigation ended without determining the cause 25 26 Inquest EditIn August 1949 the City Coroner R P Rodriguez conducted an inquest into the deaths of the 18 people on board the aircraft 12 A dispatch officer with MacRobertson Miller Aviation Note 11 observed the aircraft take off normally then climb to an almost vertical position roll over and dive vertically towards the ground twisting as it did so 12 Written evidence from the aerodrome control officer Note 12 on duty in the control tower stated that he observed the aircraft turn through 180 degrees as though in a spiral turn or spin 12 Some witnesses who lived at the South Guildford housing camp believed one of the aircraft s engines had failed by the time of the crash The City Coroner was satisfied both engines were operating normally during the takeoff and up until the time of the impact 11 12 A medical officer Note 13 conducted post mortem examinations of the bodies He confirmed there was no indication of alcohol in the bodies of any of the pilots All on board died of multiple injuries before being burned 12 A resident of the housing camp who was one of the first witnesses to arrive at the crash scene told the City Coroner she saw the air hostess in the cockpit standing beside the pilot Note 14 12 The City Coroner was satisfied that the aircraft was airworthy and neither MacRobertson Miller Aviation nor the pilot did anything negligent to cause the fatal crash 11 12 Inquiry EditOn 28 September 1949 the Minister for Civil Aviation Arthur Drakeford announced that a court of inquiry would be held to investigate the accident because the investigation by the Department of Civil Aviation had been unable to determine the exact cause Mr Justice Wolff Note 15 of the Supreme Court of Western Australia was appointed to chair the inquiry 25 The inquiry commenced on 12 December 1949 27 Observations Edit The inquiry received evidence from the aerodrome control officer on duty in the control tower at the time of the takeoff Note 16 He observed the aircraft climb at a steeper rate than any airline operated aircraft he had seen previously When the aircraft was at a height of about 500 feet 150 m the left wing dropped sharply as if in a stall The nose dipped and the aircraft seemed to rotate through 180 degrees before dropping vertically A ground engineer Note 17 also saw the aircraft climb abruptly before it nosed over and twisted twice as it dived to the ground 13 Aircraft loading Edit The inquiry heard that on 27 June 1949 the Department of Civil Aviation sent a letter to MacRobertson Miller Aviation advising that the methods used by its operational personnel to check the weight and balance of company aircraft did not conform to the appropriate requirements and that approved methods must be used in the future In response the Operations Manager for MacRobertson Miller Aviation sent specific instructions to pilots on 30 June On 1 July the day before the accident the Operations Manager discussed his instructions with the pilots of the accident flight Note 18 28 Staff involved with the loading of aircraft were instructed to use the method of Index Units to check that the centre of gravity of an aircraft was within limits The employee who loaded the freight and passengers luggage on the accident flight told the inquiry that after the freight was loaded a check of the aircraft weight and balance showed that about 80 pounds 36 kg of freight should be removed Freight weighing 102 pounds 46 kg was then removed However this employee believed the Load Sheet column labelled Index Units was not completed Note 19 8 29 There were suggestions the aircraft had been incorrectly loaded with 1 400 pounds 640 kg in the rear baggage locker when it was assumed only 1 100 pounds 500 kg would be carried there 28 29 The accuracy of statements regarding 1 400 lb was challenged 29 30 Control chocks Edit The inquiry heard that the first officer had been unable to find all the control chocks normally used to lock the control surfaces on the aircraft while it was parked There were concerns that one of the aircraft s control chocks might have been left in position instead of being removed before takeoff 21 The inquiry heard that all chocks were eventually accounted for 31 There was also a concern that one of the aileron chocks might have been inadvertently inserted in the elevator circuit Chief Inspector James Harper told the inquiry that he made some test flights in a DC 3 aircraft in a similar configuration to the Fitzroy on the accident flight One test showed that the DC 3 could be flown satisfactorily even with an aileron chock in the elevator circuit Harper was satisfied the aircraft did not take off with the elevator locked 21 Pilot competency Edit The pilot in command of the aircraft on the accident flight was Captain William Norman Note 20 Captain Cyril Kleinig an approved checking pilot with MacRobertson Miller Aviation gave evidence to the inquiry He had flown with Captain Norman on many occasions and described him as competent Note 21 12 33 A pilot who had flown the Fitzroy to Carnarvon and return the day before the accident told the inquiry the aircraft had behaved normally He also said he had flown with Captain Norman many times and found him to be careful and competent and more meticulous than most in performing his cockpit drills Note 22 31 Air hostess Edit Two residents of the housing camp who were among the first to arrive at the crash scene told the inquiry they could see two bodies in the wreckage of the cockpit a male and a female both wearing uniform so they presumed the bodies were those of the pilot and air hostess One described the female as having fairly long blonde hair Note 23 13 31 The superintendent of air navigation and safety in the western region of the Department of Civil Aviation Note 24 said the bodies of the pilot and first officer were found in their correct seats in the cockpit Particular attention was paid to the body found closest to the rear of the cabin a few feet a metre forward of the hostess s seat The body was that of a female 28 Another witness was an employee of MacRobertson Miller Aviation who raced from the airport to the scene of the crash Note 25 He contradicted the evidence that the body of a woman could be seen in the cockpit He told the inquiry the air hostess had red hair 29 Irregularities Edit The inquiry exposed certain irregularities in MacRobertson Miller Aviation s operations These irregularities centred on the loading of aircraft proper completion of Load Sheets and administrative methods 34 Counsels summaries Edit The Department of Civil Aviation was represented by Henry Winneke Note 26 30 Mr Winneke suggested to the inquiry that the immediate cause of the accident was that the pilot lost flying control of the aircraft He said the reason for this loss of control was unknown although incorrect loading of the aircraft may have contributed He acknowledged the excellent work done by the Department s accident investigators in attempting to determine the cause 34 George Pape Note 27 counsel representing MacRobertson Miller Aviation warned against speculating on what might have caused the crash and urged the court to make an explicit finding that loading of the aircraft was not a possible factor contributing to the cause of the crash 30 The inquiry sat for seven days and adjourned on Wednesday 21 December 1949 30 Report and findings Edit The report and findings of the inquiry were not released until 8 March 1950 when the new Minister for Civil Aviation Note 28 Thomas White tabled them in the House of Representatives The report confirmed that the crash occurred because the aircraft stalled and the pilots were unable to regain control However the evidence was not sufficient to allow determination of what caused the stall 26 The report conceded that over loading of the aircraft s rear baggage compartment may have contributed to the stall 37 38 The inquiry acknowledged that the operator MacRobertson Miller Aviation had distributed instructions about aircraft loading to its pilots on 30 June but considered more should have been done On the night of the accident the pilot in command had not checked the loading calculations performed by the two men responsible for loading the aircraft as he was required to do although the inquiry acknowledged there was insufficient evidence to conclude that the pilot in command was responsible for the accident The inquiry considered the man responsible for loading the rear baggage compartment possessed inadequate knowledge of aircraft loading and had been untruthful Note 29 He had invented his story to hide his over loading of the compartment 26 37 39 40 41 The inquiry was critical of the operator and the Department of Civil Aviation 26 In particular it was critical of the operator s poor standards of maintenance of aircraft instruments For this reason the inquiry recommended the operator s airline licence should be suspended or cancelled It also considered the Department should have made more checks of the operator s methods and record keeping The Minister declined to take action against the operator saying its maintenance record keeping had improved significantly since the accident He also cited the hardship that would be inflicted on many remote communities in Western Australia if the operator s airline licence were to be suspended or cancelled The Minister said his Department would be extra vigilant towards the operator but conceded there were limits to what could be done without significant increases in staff numbers 38 39 42 The inquiry was also critical of the lack of qualifications and experience of the pilot in command the late Captain Norman It said Norman should not have been promoted to captain and evidence from Captain Kleinig in support of Captain Norman was worthless It recommended that promotion of a pilot to Captain of an airliner should be at the discretion of the Department of Civil Aviation and that the Department should take account of all records and reports of tests relating to the applicant 26 37 39 The Managing Director of MacRobertson Miller Aviation Mr E C Gare rejected claims of incorrect loading on the night of the accident He also defended Captain Norman saying he had 3 500 hours flying experience and an unblemished record 43 Aircraft EditThe aircraft was constructed as a Douglas C 47A 20 DL transport aircraft with a Douglas serial number 9350 It was completed in April 1943 and assigned the military serial number 42 23488 It was delivered to the US Army Air Force in Brisbane in May 1943 9 In July 1946 it was acquired by MacRobertson Miller Aviation and ferried from the Philippines to Perth where it was converted from a military C 47 to a civil DC 3 with seating for 21 passengers 44 It was registered by MacRobertson Miller Aviation in March 1947 Note 30 9 and named Fitzroy 6 See also Edit1946 Australian National Airways DC 3 crash Accident in Hobart 1948 Australian National Airways DC 3 crash Accident in New South Wales List of disasters in Australia by death toll List of accidents and incidents involving commercial aircraft List of accidents and incidents involving airliners by locationNotes Edit In July 1949 Australia s worst civil aviation accident was the 1946 Australian National Airways DC 3 crash in Hobart that killed all 25 occupants The second worst was a Lockheed 18 Lodestar that crashed at Coolangatta in March 1949 killing all 21 occupants Third worst was shared by two that caused the death of all 18 occupants the 1938 Kyeema crash east of Melbourne and the Fitzroy at Perth airport The crash of the Fitzroy remained the worst in Western Australia until June 1950 when the DC 4 Amana crashed near York killing all 29 occupants 1 MacRobertson Miller Aviation merged with Airlines WA in late 1955 and was re named MacRobertson Miller Airlines MacRobertson Miller named its aircraft after West Australian rivers 5 6 The Perth to Darwin service made intermediate stops at Carnarvon Port Hedland Derby and Wyndham 9 The Douglas DC 3 is operated by two pilots On this flight there were two pilots and a supernumerary pilot in the cockpit The supernumerary Captain Eric Charles Langford was travelling as far as Derby to take command of another flight 2 10 Formerly Guildford Army Camp 14 Some sources named the housing camp as Camp No 22 15 One source stated the clear area was 100 feet square 17 Other sources stated the wreckage of the Fitzroy was mostly concentrated in an area 20 yards 18 m square 18 Fireman Arthur David James Firth said that at least 3 fire tenders would have been necessary to extinguish the fire 13 The officers from the Department of Civil Aviation s western region were Robert Walter Ridley and R K Pritchard 16 The panel consisted of Chief Inspector James Herbert Harper and Accident Investigator James Edward Schofield 20 21 22 The position of passengers and cargo was not known precisely The position of the centre of gravity was most likely to have been between 2 0 and 4 7 of MAC behind the rear limit 24 The dispatch officer was Vivian James Dandridge 12 Another source described him as a ground engineer 13 The aerodrome control officer was Ronald David Dyson 12 Another source named him as Raymond David Dyson 13 Alan T Pearson district medical officer 12 The witness was Mrs Gwendoline Gilbert Her statement that she saw the air hostess standing in the cockpit beside the pilot was at odds with other evidence including evidence from post mortem examinations of the bodies 12 Albert Wolff was appointed Chief Justice of Western Australia in February 1959 He was knighted in June 1959 The aerodrome control officer was Raymond David Dyson 13 Another source named him as Ronald David Dyson 12 The ground engineer was Vivian James Dandridge who tested the engines prior to the fatal flight and found them to be operating normally 13 Another source described him as a dispatch officer 12 The Operations Manager was Kenneth Cohen 28 Colin Oliver Mason senior despatch officer for MMA gave evidence regarding the weighing of passengers and their luggage but said he did not believe it was his responsibility to complete the Load Sheet column labelled Index Units The employees who loaded the freight and passengers luggage were Robert Woods and Ronald Butler 29 Captain of the aircraft was William Graham Norman unmarried aged 27 years 2 He served in the RAAF until joining MMA in July 1947 32 The approved checking pilot was Cyril Nathaniel Kleinig Assistant managing director of MMA 12 33 The witness who had flown the Fitzroy the day before the accident was Arthur Edward Budd Budd had flown as First Officer with Captain Norman on many occasions 31 The witnesses were George Robert Forbes and Harry John Jones Their evidence regarding the air hostess in the cockpit was at odds with other evidence presented at the inquiry including evidence from post mortem examinations of the bodies 13 31 Mr Eorl Huntley Fry 12 The witness was Colin Oliver Mason senior despatch officer for MMA 29 Sir Henry Arthur Winneke was knighted in 1957 and later became Chief Justice of the Supreme Court of Victoria 1964 and Governor of Victoria 1974 George Augustus Pape later Sir George became a Justice in the Supreme Court of Victoria in 1957 and served until 1975 35 The Australian labour government in which Arthur Drakeford was Minister for Civil Aviation was defeated at the federal election on 10 December 1949 A coalition government of conservative parties was formed with former AFC pilot and RAAF officer Thomas White as the Minister for Civil Aviation 36 See Fourth Menzies Ministry Ronald Frederick Butler 29 The aircraft was registered VH AXM in March 1947 ICAO subsequently prohibited use of registrations beginning AX so the aircraft was re registered VH BXM in November 1948 It was re registered VH MME in December 1948 9 References Edit a b Earlier Air Disasters In Australia The West Australian 27 June 1950 p 1 National Library of Australia Retrieved 11 November 2011 a b c d 18 Killed In WA s Worst Plane Crash The Argus 4 July 1949 p 3 National Library of Australia Retrieved 11 November 2011 a b c d All Killed When Airliner Crashes At Guildford The Sunday Times 3 July 1949 p 1 National Library of Australia Retrieved 11 November 2011 Air Safety Record The West Australian 4 July 1949 p 4 National Library of Australia Retrieved 11 November 2011 2 mil air co formed The Argus 24 June 1955 p 16 National Library of Australia Retrieved 11 November 2011 a b History of MacRobertson Miller Airlines RAAF Association of WA Retrieved 14 September 2016 Guildford Disaster The West Australian 4 July 1949 p 2 National Library of Australia Retrieved 11 November 2011 a b c Job 1992 p 113 a b c d Aussie Airliners Retrieved 11 November 2011 a b c 18 Incinerated In W A Plane Crash The Mail 2 July 1949 p 1 National Library of Australia Retrieved 11 November 2011 a b c No Negligence In Plane Crash The West Australian 26 August 1949 p 12 National Library of Australia Retrieved 11 November 2011 a b c d e f g h i j k l m n o p q Evidence At Guildford Air Crash Inquest The West Australian 23 August 1949 p 9 National Library of Australia Retrieved 11 November 2011 a b c d e f g h i j Ill Fated DC3 Turned Over Backwards The West Australian 13 December 1949 p 8 National Library of Australia Retrieved 11 November 2011 Ozatwar Peter Dunn s Australia War Retrieved 11 November 2011 a b Brief Story Of Crash The Geraldton Guardian 2 July 1949 p 3 National Library of Australia Retrieved 11 November 2011 a b c Tangled Wreckage Of DC3 At Guildford The Sunday Times 3 July 1949 p 2 1 National Library of Australia Retrieved 11 November 2011 a b Airliner In Flames After Crash The Sunday Herald 3 July p 3 National Library of Australia Retrieved 11 November 2011 a b Cause Of Air Crash Not Known The West Australian 4 July 1949 p 3 National Library of Australia Retrieved 11 November 2011 Tender Driver Fought Fire The Sunday Times 3 July 1949 p 2 2 National Library of Australia Retrieved 11 November 2011 a b Plane Crash Report Ready Tomorrow The Argus 5 July 1949 p 7 National Library of Australia Retrieved 11 November 2011 a b c d Alleged Ordeal In Airliner The West Australian 20 December 1949 p 7 National Library of Australia Retrieved 11 November 2011 Water In Tanks Worry To RAAF The Courier Mail 16 February 1951 p 3 National Library of Australia Retrieved 11 November 2011 a b Job 1992 p 114 a b c Job 1992 p 115 a b Air Tragedy Inquiry The West Australian 29 September 1949 p 16 National Library of Australia Retrieved 11 November 2011 a b c d e Job 1992 p 116 Air Disaster Inquiry The West Australian 5 October 1949 p 24 National Library of Australia Retrieved 11 November 2011 a b c d Loading Discussed Before Crash The West Australian 16 December 1949 p 12 National Library of Australia Retrieved 11 November 2011 a b c d e f g Load Distribution In Crashed DC3 The West Australian 15 December 1949 p 8 National Library of Australia Retrieved 11 November 2011 a b c d Counsel s Submissions At Air Crash Inquiry The West Australian 22 December 1949 p 11 National Library of Australia Retrieved 11 November 2011 a b c d e Chock Found On Tarmac After DC3 Crash The West Australian 14 December 1949 p 13 National Library of Australia Retrieved 11 November 2011 Died In Crash The Sunday Times 3 July 1949 p 2 3 National Library of Australia Retrieved 11 November 2011 a b Earlier Behaviour Of Crashed DC3 The West Australian 17 December 1949 p 4 National Library of Australia Retrieved 11 November 2011 a b Irregularities Exposed In Crash Inquiry The West Australian 21 December 1949 p 14 National Library of Australia Retrieved 11 November 2011 Job 1992 p 131 New Menzies Ministry Announced The Canberra Times 19 December 1949 National Library of Australia Retrieved 8 May 2012 a b c Critical Report On Air Crash The West Australian 9 March 1950 National Library of Australia Retrieved 5 March 2012 a b Drastic Penalty For W A Airline Avoided The Canberra Times 9 March 1950 p 4 National Library of Australia Retrieved 5 March 2012 a b c Air Crash Inquiry Findings The West Australian 9 March 1950 p 4 National Library of Australia Retrieved 5 March 2012 Air Crash Report The Sydney Morning Herald 9 March 1950 p 5 National Library of Australia Retrieved 5 March 2012 Air firm was warned days before crash The Argus 9 March 1950 p 8 National Library of Australia Retrieved 5 March 2012 Job 1992 p 117 Comment By M M A The West Australian 9 March 1950 p 4 National Library of Australia Retrieved 5 March 2012 Airport Round Up The West Australian 15 March 1947 p 14 National Library of Australia Retrieved 11 November 2011Bibliography EditJob Macarthur 1992 Air Crash Vol 2 Chapter 8 Aerospace Publications Pty Ltd Fyshwick Australia pp 200 ISBN 1 875671 01 3External links EditAviation Safety Network Retrieved from https en wikipedia org w index php title 1949 MacRobertson Miller Aviation DC 3 crash amp oldid 1158112729, wikipedia, wiki, book, books, library,

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