Investigation Summary
The investigation into the loss of the Lutana focused on why a highly experienced crew, led by Captain J. A. Drummond, was flying 100 miles west of their assigned track. The inquiry identified a 'perfect storm' of navigational failures. First, an electrical storm in the vicinity likely caused the aircraft's magnetic compass to deviate. Second, the Kempsey radio range, a critical government-maintained navigational aid, was found to have suffered a temporary defect that provided misleading signals to the cockpit. Furthermore, the aeronautical charts provided to the pilots contained significant errors regarding the height and location of terrain in the North West Slopes region. The combination of these factors led the crew to believe they were on a safe course when they were actually heading directly toward the 4,600-foot Square Peak. The crash was so significant that it triggered a complete reorganization of the Australian Department of Civil Aviation's air traffic control system.
Final Conclusions
The Air Court of Inquiry, led by Judge William Simpson and released on 17 November 1948, concluded the probable cause was a combination of navigational equipment failures. Specifically, it cited interference with the magnetic compass due to an electrical storm and a temporary defect in the Kempsey low-frequency radio range signals. The inquiry also noted that deficiencies in official aeronautical charts contributed to the crew's inability to recognize their proximity to high terrain.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Systems & Failure Modes
Magnetic Compass
The primary heading reference, which the inquiry found was likely affected by interference from a nearby electrical storm.
Kempsey Low-Frequency Radio Range
A ground-based navigational aid that reportedly emitted defective signals, leading the crew to an incorrect position fix.
Aeronautical Charts
The inquiry identified errors and deficiencies in the charts used by the crew to navigate the mountainous terrain.
Interesting Facts
- 01The aircraft was approximately 100 miles off course at the time of impact.
- 02The crash site was located on Square Peak at an elevation of 4,600 feet.
- 03The inquiry described the pilot, Captain J. A. Drummond, as a pilot of more than ordinary ability.
- 04The aircraft was a Douglas C-47A-50-DL manufactured in 1943.
- 05The accident led to a major reorganization of the Australian Department of Civil Aviation's air traffic control system.
- 06Among the ten passengers killed was Margaret McIntyre, the first woman elected to the Parliament of Tasmania.
Safety Actions & Advisories
Air Traffic Control Reorganization
The accident led to a complete reorganization of the Department of Civil Aviation’s system of air traffic control in Australia.
Chart Revision
The inquiry prompted a review and correction of aeronautical charts that previously contained terrain height and location errors.
Known Controversies & Unanswered Questions
Ministerial Objection to Findings
Reference ↗Air Minister Arthur Drakeford publicly objected to the inquiry's findings, calling them inconclusive and disputing the claim that the Kempsey radio range station had malfunctioned.