Investigation Summary
The investigation into Flight 4210 highlighted a combination of technical failure and operational deficiencies. The left engine failed shortly after takeoff from Runway 25, which investigators attributed to water ingestion. The aircraft reached a maximum altitude of 150 feet AGL before the pilot leveled off and began a shallow bank to the left. Although the source of the water was never conclusively identified, elemental analysis suggested it had been in the fuel system for some time. The aircraft's performance was further compromised by environmental and weight factors: the ambient temperature was 39C (102F), and the aircraft was approximately 128kg over its maximum allowable weight due to the airline's use of estimated rather than actual passenger weights. Crucially, Advance Airlines had implemented a company procedure advising pilots to use reduced power settings during takeoff to minimize engine wear. This procedure had not been approved by the Department of Transport. The Board of Inquiry found that the combination of reduced power, high heat, and excess weight rendered the aircraft's single-engine performance critical. The pilot, facing a high workload, was unable to successfully execute the emergency return to Runway 34, ultimately impacting the seawall in a nose-high attitude.
Final Conclusions
The Board of Inquiry, chaired by Sir Sydney Frost and published in 1983, attributed the accident to pilot error and the presence of water in the fuel tank. The inquiry noted that the pilot's handling of the emergency was hampered by the aircraft's critical performance state, caused by the unauthorized use of reduced takeoff power and the aircraft being overweight. The investigation also cited the high cockpit workload for a single pilot during an engine-out emergency as a significant factor.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Systems & Failure Modes
Pratt & Whitney Canada PT6A Engines
The left engine failed due to water contamination in the fuel system, which led to a loss of thrust during the critical initial climb phase.
Fuel System
Investigators found evidence of long-term water contamination in the left fuel system, though the exact entry point or accumulation site could not be determined.
Interesting Facts
- 01The aircraft was 128kg (282lb) over the maximum allowable takeoff weight.
- 02The ambient temperature at the time of the crash was 39C (102F).
- 03The airline used a reduced power takeoff setting that was not approved by the Department of Transport.
- 04The total flight duration from brake release to impact was 106 seconds.
- 05All 12 passengers were residents of the Temora district, including a one-week-old infant.
- 06The flight was a multi-leg service scheduled to continue to Condobolin after stopping at Temora.
Safety Actions & Advisories
Two-Pilot Mandate
The Australian aviation regulator implemented a requirement that all commercial aircraft operating in Australia with more than nine passengers must be operated by two pilots.