Investigation Summary
The aircraft was performing a trooping flight, carrying 45 military personnel and 5 crew members. Shortly after becoming airborne at 12:21 UTC, the boost enrichment capsule in the carburetor of the number one (outer port) engine failed, causing a fire and a total loss of power from that engine within 30 seconds. Despite being cleared for a right turn, the aircraft drifted to the left in a yawing motion. The crew failed to feather the propeller of the failed engine, which created significant drag. As the aircraft climbed slowly to approximately 700 to 800 feet, the flaps were retracted while the aircraft was still in a nose-high attitude at low speed. This combination of drag, low speed, and high pitch resulted in a stall. The aircraft entered a steep dive and crashed into fields near the town of Żurrieq, exploding on impact.
Final Conclusions
The official inquiry concluded that the mechanical cause was the failure of the number one engine due to cracks in the boost enrichment capsule. However, the crash was ultimately caused by a loss of speed and subsequent loss of control due to an error of judgment by the pilot. Specifically, the captain failed to use the rudder to stop the leftward swing, failed to correct the nose-high attitude to gain flying speed, and failed to feather the propeller of the failed engine. The court also noted that while the captain had practiced engine-out procedures, those tests were conducted at significantly lower weights (55,000 to 57,000 lbs) than the accident flight's weight of 68,000 lbs.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Systems & Failure Modes
Boost Enrichment Capsule
A component in the carburetor that failed due to cracking, leading to an incorrect fuel-air mixture and subsequent engine fire.
Propeller Feathering System
The mechanism used to turn propeller blades parallel to the airflow to reduce drag after an engine failure; it was not activated by the crew.
Rolls-Royce Merlin Engines
The four liquid-cooled piston engines powering the Avro York; the No. 1 engine failed during the initial climb.
Interesting Facts
- 01Twelve of the RAF passengers had won their seats on the flight through a 'lucky draw' to avoid a long sea voyage home.
- 02The aircraft was carrying approximately 2,000 gallons of high-octane aviation fuel at the time of the crash.
- 03The investigation considered sabotage but found insufficient evidence to support the theory.
- 04The aircraft was a converted military transport purchased from the RAF in 1954.
- 05The crash was the worst accident involving an Avro York at that time.
Safety Actions & Advisories
Trooping Flight Inquiry
The Secretary of State for Air faced parliamentary questioning regarding the safety of using aging Avro York aircraft for trooping missions and the weight limits for three-engine performance.