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THEE ACCIDENT
The regional routes own by Brisbane-based Queensland Ai A rlines were pros os sspe pe pp ri r ng by e
As usual, the service from Brisbane to Coffs Harbour via Coo ola la aang ng ng ng gat tta ta ta ta and Casino and
Thursday, 10 March 1 1949 was to o be own by one of the co co omp m anys s Lo Lockheed 18 Lo ooode
Lodestar VH-BAG carried a crew o of f th th thre re re ree: e: e: e: cccc ccapppptain, rst ofcer an aa d ight h a aaattendant.
from Brisbanes Archereld airp por ooo t at 7.45a aaam, VH-BAGs southbound ight wa was s norma
way, and it landed at Coffs Harbour at 9.20am. The day was ne and clear, with h a a a lig
fr from o the east.
Af A te err r th th th the e eso so southbound passengers alighted, the oil company agent refuelled the eLo Lo Lo Lock k ck ckhe he he he h ed eee . Th
was tted d w wit ith h fo four wing tanks installed inboard of the engines on either side, and nd 100 gaa
octane avgas was s pum mmpe p d into the two forward tanks, almost topping n them up. Ei Eigh ght p
boarded the aircraft, and d th thei e r luggage loaded into the roomy nose compartment.
The Lodestar took off at 9.550a 0am, landing at Casino 35 minutes later. Threee p
disembarked, and another six, all l bo bo b oked e to Brisbane, joined the ight. A Aga g in the heir lug
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Sixty years onnn,, FFFFFFFFFFFFFlllliiigggght Safety wrrrriiiitttter, Maacaaaaaarrtttthhur Job, looks
y
at how a loaddinngg ppprroblem led to one of AAAuuusssttrraallliaaas worst
il
i tion accidents
cciviil aviation accidents.
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At 11.15, , wh wh wh h when en en eee the Lodestar had be be be een en en en on the ground for less sss th th th th than an an an a aaaa
qu qu quarter of an ho hh ur, the engines were sta aart rt rt rted ed ed ed, aan aa d the ma m chin ne e ee ta ta ta a taxi xi xied ed ed ed e
away to the e western end of the east-west str tr tr trip ip ip ip. . Th The airc rc r ra ra aaaft ft ft ft t dd ddid id id id nn nnot ot ot ot ot
appear to o pause near the threshold, but began its ta ta ta take ke ke keof of of off f ff in i to t the he he he eeeeas aas ast ttt
almost tt iiiimmediately.
Beco ccc ming airborne about half way along the strip, it connti tiinu nu nu nued tooo o
y close to the ground as it accelerated. Then, as the underc car aaa riagggge e
retracted, it began to climb. The angle of climb appeared norm rm rm mal al al al
at rst, but within seconds, those watching from the terminal wwwer er e e eee
abbergasted to see the Lodestar nosing up into an impossibly s sste teeeep ep ep ep
climb. What the hells the matter with him? the airline driver ccri ri ri ried ed ed ed
out in alarm.
With the engines still at take-off power, the climb co co cont nt nt ntin in in i ued to s ste t ep epppen nn
as the aircraft gained height. Some watching ng ng ng ng gg ttt tho ho ho ho hhh ught it wo w uld go ove ve v r r
on its back, but when abnormally y n nnnos os os os os oo eee- eeee up at between 200 and d 300 00
feet, its starboard wing dropp pp pp pped ed ed ed d aaaannnd the machine lost height. The wing g
was picked up as the L LLLod od od od dees estar hesitated slightly. Then the port wing g
dropped steepl pl pl ply y y y an an an andddd the machine entered a curving descent to the
left ft, , gr g ad ad ad adua ua ua ua u ll ll ll llyy assuming a more level attitude as it did so o oo at low speeeeed ed dd. .
Re Re eega ga ga gain iin ining a at attitude still well above the ground, it drop pppe pe p d al almo mo ost st st st
vertical lly into a swampy area between the airstrip and the beach ch ch ch h, , , hi hi hh tttin in n i g g g
the e ground heavily on its belly and exploded into ames, thick kk bl bl bl blaac a k
smoke billowing skywards as re engulfed the wing gs s and d fuselage gg .
Deeply shocked, the groundsman and a aaage ge gents staff grabb bed re
looad ad ded into the nose comparttment. At 10.35
the aircraft took off again and after r a further
25 minutes, arrived over Coo oolang gggat at at at a ta ta ta ta.
Coolangatta aerodr dd om om mme then was on the site
of the hhee ppppre re rr sent airport neaar the township of
Bilinga, but consisted only of three relatively
short unpaved strips cut fro r m the surrounding
coastal scrub. Two of th t em were on the
approximate alignments sss of todays runway ys, s,
with the third interse eeecting strip (today y ay ay a
taxiway) running in aan easterly dire re ect c ion
towards the beach.
Overying gg, th the ee Lo LLo Lo LL de de de de d star made a left-hand
ci ircuit and touched down smoothly into the
eaast. Taxiing ahead to the strip intersection,
it tur u ned left and continuued to the north-
western end of what is todays Runway 32,
shutting down in front o of Queensland Airlines
small airport term rminal. The occupants
disembarked, fou ou ouuuuur rr of the passengers leaving
the aircraft.
Fo FF r th the e rema m ining leg ba ba ba back ck ck ck t to o o o Ar Ar Ar Ar AA ccch chereld,
another 11 passse se se eng nger er e s s joiiiined ed ed ed the ight,
making a total of f 18 18 18 18. TTThey inclu uuude de de dedd d d d th ttt e chief
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mechanis is is ismm indica ca ca ate te te ted a setting gggg of of of of f aaabo bout three divisions nose-upa
ty ty typica cal l sett t ing for land nd nd ndin in in ing. g. gg. g. g Ex Ex Ex Exaaamination of the victims showed that all
had di d ed instant nt tly ly ly ly i iiin n n n the immmmpa pa pp ct.
VH VV -BAG AG AG AGs s s s u uuupp weight when it it ttoo oo oo ook kkk off was slightly less than the
ma ma ma maxi xi xi ximmmum, and the loading gures u use e se ed d d by Queen ensl s an and d Airlines and in
th th h the passenger waybill revealed only mi mino no oor r rr di dd screpancies. I It t wa wa wa was s s s li li li li like ke ke ke keely ly ly ly
th th th that VH-BAGs weight at take-off would have e be be een en en en under t the hee he maximum
peerm rm rr issible 16,800 pounds.
CCCCENTTRRE OF GRAVVVVIIIITTTTYYYY
VH VVV -B BAGs Certi t ca ca ca a c te te te te t of Airworthiness (CofA) specied that its cent ntre re re re
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Becaus us sse e e e th ttt e disposition of the passengers
in the cab abb abin in in in wwwas a uncertain, investigators
calculated the mmmmos ooo t favourable and most
adverse combinations nsss, , , , us usin ing the weights of
all items making up the load d. Th T ese indicated
that VH-BAGs centre of gravity on beginning
takeoff would have been at bes st t 41 41.88 per
cent MAC, and at worst 42.4 per cent M MMMAC.
But when the undercarriage retracted, thes ese e
would have increased t tto 43.4 per cent and d
43.9 per cent MAC respectively -- betwwee e n 4. 44 4
per cent and 4.9 per cent MAC taillll-h -h -h -heavy.
STEEP CLIIIIMMMMMMMBBBBB
Th TTT e Lo Lo ooode de de de de dessssstars tendency to climb steeply
af af af af fte te te terr liftoff had been noticed on a number
of occasions, particularly when the loading
was tail-heavy. The companys operations
supervisor recalled an insta anc n e with a captain
under training. The Lodest st tar a had a fful u l l
complement of passengers, and ddd he he hh told the
pilot he was checking that about 10 000 di di dd visions
of nose-down trim wa as s ne ne n cessary for ta ta take kk off
with 15 degrees of ap.
The pi pi pi pi pp lo lo lo lot tttt under training however, wound on
on oooo ly about six divisions of nose-down trim,
an an a d the supervisor decided to allow the trainee
to lea earn rn the les ssso sss n for himself. The ground
run was normal, the airspeed increasing to
110mph without difculty holding the aircraft
down. But when the trainee allowed t the he he
aircraft to lift off, ,, and climb at this speed, he
was startled at the force necesssary to hold
Queenlandd Airli li li iines
nes
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L L
ockheed Lode destar V VH-B
H-B
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B
H-B
H-BAG undergoing
servicing at Br risb isb is s
ane
ane
ann
s Archer
her e eld Airport. .
VH VV BAG s Certica ccc te of Airworthiness (CofA) specied that its cent ntre ree iness (CofA) speci
of gra r vi v ty ty ty tyy m mmmust lie between 28.5 per cent and 39 per cent of the wings s ween 28.5 per cent and 39 per cent of the
me me me mean ann aerodynamic c chord (MA MMM C) (i.e. between those percentages of mic chord (MA MMM C) (i.e. between those percentages
th hhhe e aver e age distance from the leading edge of the wing to its trailing stance from the leading edge of the wing to its trailing
ed ed ddge e). For calculating the centre of gravity, the Department provided a alculating the centre of gravity, the Department provided a
lo lo lo load ad ad ad cccchart with the CofA, with load sheets to use with the he chart. with the CofA, with load sheets to use with the he chart.
AAA AA Depa pa pa part rt rt rtme me me ment nn al aeronautical engineer determining VH-BA BAG G G s s s s ac ac ac acctu tu tu tu tu ual me me me ment nn al aeronautical engineer determining VH- AAG G G s s s s ac ac ac acctu tu tu tu tu ual
ce ce entre re of gr grrav av av avit it it ity y y y at the time of takeoff uncovered som om mme di d smaying gr grrav av av avit it it ity y y y at the time of takeoff uncovered s e di d smaying
in i conssis is is s i te ttt nccie ie ie es. T TThe he he he ll loa oad chart contained a number of errors, resulting enccie ie ie es. T TThe he he he ll loa oad chart contained a number of errors, resulting
fr fr fr from oom om m ddddis i crepanci iies bbbet et et etwe wwe ween en e Lockheed 18 11 data supplied by the RAAF repanci iies bbbet et et etwe wwe ween en e Lockheed data supplied by the RAAF
(o (o (o (on n n n nn wh wh wh wh hic ic ic ic i h th the De De De Depa part rrr ment nt t hhhhad ad aa based the chart), and original gures th the De De De Depa part rrr ment nt t hhhhad ad aa based the chart), and original gures
ob ob ob obta ta ta tain ined ed d ed ed f fro rooomm m m th th th the e U. UUU S. CAA. Th Th Th The e ee pa passenger seats were also 25mm omm m m th th th the e U. UUU S. CAA. Th Th Th The e ee pa passenger seats were also 25mm
fu fu fuu fu furt rt rt rt rthe he he he hherr r r r ap ap ap ap apar ar ar arrtt tt th th than aaa indicated on th he e ch char a t, resulting in a signicant th th han aaa indicated on th he e ch char a t, resulting in a signicant
re re re e re r ar ar ar arwa wa wa wa ard rd rd rd mmmmmov ov ov ovem em em em e en en eent of the hhh centre of gravi vity ty wwwit ith all seats occupied. nnt of the hhh centre of gravi vity ty wwwit ith all seats occupied.
Th Th Th hhe e e e e ch ch ch ch har ar ar ar a tttt on on on on only ly ly ly ly y ppppro ro rr vi vvv de ddd d for the aircrafts unde de derc rcarriage down d for the aircrafts unde dd arriage down
co co co oooond nd nd nnd n it it it i io io io ooon, n, n, n, n yyy yyet et et ett rrr ret et et et e ra ra ra ra ract ct ct c in in in ing g th the undercarriage moved the ce cent ntre of gravity of gravity
fu fu fu fuu fu furt rt rt r he he he hheer rrrr re re re ee rr aaar ar arwa wwa wa wa w rd rd rd rd rd...
was startled at the force necessary to hold
th th th the ee control column forward. The captaiin to t ld told
him m to to tt apply more nose-down tr trim imm, and the and the
aircraft t the h n climbe ed d d d no nnn rmally. From the From the
load sheet ffffor or or or tttthii his ight it was determined s determined
thatt, , , , wi ww th th t the u und nd dercarriage retracted, the th the ercarriage retracted, the
Lodestar a s centre of of ggra r vity was just Lode s centre vity was just behind behind
the stipulated rear limit. the stipulated rear limit.
At the next pilots meeting, t the he he operations At the next pilots meeting, t the he he oper
supervisor pointed ed ed ed d out the impor rta tanc nce of at supervisor poi ted ed ed ed d out the impor rta ta
least 10 divisions of no no no nose se se se-d -d -ddown trim, to oge ge eeth th th ther least 10 divisions of no no no nose se se se-d -d -ddown tr
with the necessity to ke ke ke keep ep a all ll ll ll load forwarrd, ddd, with the necessity to ke ke ke keep ep a all
with 16 passengers on board. d. with 16 passengers on boar
About a month before the aacc cccid id i ent, the About a month befo
companys senior check pilot also expe peeerienced companys senior check pilot also expe peeerienced
a steep climb. The aircraft beca aaame air rrrbo bbb rne a steep climb. The aircraft beca aaame air rrrbo bbb rne
normally after a short run un, but almost normally after a short run un, but almost
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immme m diately began to climb steeply. Even with both hann annds ds ds s ds, he he h was
unable to force the control column forward. Wh Wh W en the airspee e d had
fallen to 85mph, rather than risk ta aaki ki ki ki k ng ng ng ng o ooone hand off the wheeeel to adjust
the elevator triim, he rais ii ed d t ttthe hhh aps. This immediately alter eee ed the trim
of the aircrrraf af af ft, tt t tthe h wheel m moved forward, and the clim im im i b continued
norm mmally. Thinking this inci c dent over, the check pilot t tthought he might
have begun the takeoff with less than 10 ddivisionss oof nose-down trim.
Even so, he was certain so some nose-down trim wa wa w s applied.
Asked if he had ever not ot ticed a tendency towa w rds instability in ight,
the e senior check pilot rrec e alled an occasionnn n when, with a full load of
passengers, no luggage e in the nose com mpa pp rtment, and only a light fuel
load, he found it imposs sss ible to trim the he h aircraft to y level. Constantly
hunting long gitudinal al a ly ly ly ly ly yy, , it it it it wwwas as as as uuuunp np np nple le le leas as as assan an an an a t ttt to to to to y yyyy.
Information was soug ught from the U.S. CAA, and from
the Lockheed Aircraft Corporation, on the handlin
charracteristics of the Lodesta tt r aircraft with the centr
of gravity behind the rear a limit. This established tha
the centre of gravity rear limit had been amended
from 40.6 per cent MAC to 39 per cent. From this, thee
investigators conc nc nnc ncclu l ded that VH-BAGs longitudin nnal al al al
instability would re eeeeac ac aa h dangerous propppppor or or orti ti ti tion o s at
43.4 per cent t t MA MM C, the p pppro ro ro robable pooosi si si i ss ti ti ti ti t on on on on aat the time
of the accid ddden en en ent. t
LOAD CCCCHHHHAAAARRT
Th Th Th The in investigators now turned their atten enti tion on o to
the grave error in VH-BAGs load distribut ut ttiio ion, n,
and to what extent the companys practices had ad
contributed to it. A clause in the Certicate o oooof ff f
Airworthines ss stated: The aircraft must b bbbbe eeee lo lo lo loaded
in accordance e with the attached lo lo o load aad ad chart which
is part of this Certicate. eee Furthermore, the
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Departmental loa aaad d dd dd sh sh sh s eets for calculating the eets for calculating the
centre of gr gr g aaavity, using index uni its tt derived vity, using index uni its tt derived
from om om om m o t the load chart, stated: Index units MUST oad chart, stated: Index units MUST
be supplied except where an approved loading plied except where an approved loading
procedure or approved loading slide rule is edure or approved loadin slide rule is
in use eee. . BBBut ut because an Air Navigation Order use eee. . BBBut ut because a
covering t thi hi hi his ss s re re re requ q irement had not yet been vering t thi hi hi his ss s re re re requ q ir
written, the prooce ce ce cedu du du dure rrr was still not mandatory. itten, the prooce ce ce cedu du du d
The operations supervi vi viisso soor r to told the investigators e operations supe
that although a load charttt wwwwas as as as always carriiied at although a load c
on the aircraft; the pilots were e fa fa fa fami miliar enough the aircraft; the pilots wer liar enough
with thee aircraft to o be ab ab a le to load it bby by b rref eference thee aircraft to o be ab ab a le to load it by by rref eference
to the loa oad sheeet t which showed the w wei eigh ght o loa oad sheeet t which showed the w wei eigh ght o
passengers, luggage and freight. The senior chec ec s, luggage and freight. The senior chec ec
pilot enlarged on this, explaining that pilots followe pilot enlarged on this, explaining that pilots follow
general rules for loading. The nose compartme gen
was lled rst, the No 2 compartment from t was
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The Lockheeds twin- nned tail assembly survived the re, but shows
downward distortion from the high vertical impact.
d
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the
The burnt-out remains of the Lockheed, after it fell almost vertically into
swampy ground.
front next and so on, irrespective of passenger load d ad d. Th Th Th Th h The passenger
load was disposed about the main spa pp r, r, llli ling gg the front nt seats rst.
The front fuel tanks were also so so soo llllle le led rst. The senior ch check pilot said
that the load charrt ttt wa w s never used on regular schedu uules as there was
not suuuf f fc cccie ie ie ent time. He He believed the general ruleeees s for loading were
adequate, except when n heavy freight was being g g ca c rried.
This was obviously not ot so. In view of the time V VH- HH BAG had been in service,
the variations in load d encountered, the instan ances of rear centre of gravity
instability experience eeed, and the quite unrem emarkable loading at Coolangatta t
which produced suc ch hh dire consequence es, ss, it seemed likely that VH-BAG had
been own in a dang n erously tail-heavy vy vv condition on numerous occasions.
Why then was theee cre r w w un unab able le ttoo o o cco co correct the powerful nos os o e- e up up up up ttten en en ende dee denc nc nc n yy y y
af after th th th t e e take ke ke k of of fff f ff fffffffrom Coolangatta when others had got away with it?
Did some other factor exacerbate the tail-heavy condition, preventing
the crew from taking acttion to avoid the accident?
Th Th T e e investigators beliieved the answer was the setting of the elevato or r r
tr rrrim. The position of the trim tab cables on the mechani nism sms sss sssspo po po pool
sugges ee ted the take k -off could have begun with the eleva va ato to to o tor r r r tr tr tr triim still in
the position onnn to ooo which it was adjusted for the e la laand nd nd ndin in in inggg at Coolangatta.
If this were t ttthe he he he hh case, the crew would ha ha aave ve ve ve had d no hope of applying
sufcient ttt f ff forwarddddd fff for ooo ce on the cont nt ttro ro ro ro r l l ll co colu lumn to prevent the nose rising
st steeply as the machi hii hine ne ne ne acc ccccel el el el eeler er er eerat aat a ed after takeoff. The experiences of
the se s ni ior cheeck ck ck ck pp ppilot ot tt and nd dd ttt the he he h operations supervisor showed that, when
taking off wit it th h hh aaaa rrearward c cccen en en entr tr tr tr re ee of gravity and 15 degrees of ap, the
ai a rcra aaaft ft ft ft f ee eexh xh xh xhibited a nose-up tennde de de denc nc nc n y y that w wwas difcult to overcome,
ev ev ev even en en en with some nose-down trim. WWit it th hh h th the trim iina aadv dver erte tent nt tly ly y left in a
nose-up setting, it would be impossible.
Wh Why the crew overlooked such a vital action n re rema ma ma ma aain in in ined unanswered.
Though it was not the companys practice to o us us us us u eee ee any y fo fo orm rm rm rm of check list,
all crew ew wwss ss followed a standardised checking
procedure. TT TThe hhh re ee was evidence that the
captain and traf af af afc c cc manager had quarrelled
immediately before VVVVH- H- HH BA B G taxied away
from the terminal, but any b bea earing this might
have had on the oversight remained a matter
of conjecture.
THE RECOMMENDATIONS
The investigators report conclu ude ded d wii with
two principa p l recommmendationnnnns: s: s
That all airlines b be ee subject to periodic
checking b bbbbby y y yyy DDDepartmental ofcers to
ensu su uuure re re re re r thhat no company practice was
c c c c ontrary to the interests of safety.
That responsibilities for the safe loading
of aircraft, and the procedures to be
followed, be dened i in n Air Navigationn
Orders and promulgated w wwithout delay ay.
Their report made no mention oof f ff th th hhe ee loose
system of cockpit checking n that cont nt nttri r buted
to this tragedy. But t thi hiiis, s with other disaaast st ss ers
overseas res sssul ul ul ulti tiing from the neglect of vital al al al
pre- e ta ta ta a ta ake kke ke-off actions in modern complex
aircraft f , would eventually point the way
fo fo for r the e adoption of tighter, more positive
systems based on some form of written
check list.
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Undercarriage down, the Lockheed prepares to land. Note the extended wing aps.