On 2 July 1949 a Douglas DC-3 aircraft departed from Perth Airport for a night flight of to Carnarvon. The aircraft climbed to a height of about and then spiralled almost vertically to the ground, killing all 18 people on board. It crashed about north of Perth Airport and burned for over one hour. At the time, it was the worst civil aviation accident in Western Australia."18 Killed In WA's Worst Plane Crash" The Argus – 4 July 1949, p.3 (National Library of Australia) Retrieved 11 November 2011"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
The flight The aircraft was the airliner Fitzroy, registered VH-MME and operated by MacRobertson Miller Aviation."Guildford Disaster" The West Australian – 4 July 1949, p.2 (National Library of Australia) Retrieved 11 November 2011 On 2 July 1949 it was about to conduct the regular passenger service from Perth to Darwin which departed about 2am to allow passengers to connect with the twice-weekly Sydney to London flight operated by Qantas. The first stop was to be Carnarvon. On board were three pilots, an air hostess and 14 passengers. The aircraft took off at 2:14 am in driving rain."18 Incinerated In W.A. Plane Crash" The Mail – 2 July 1949, p.1 (National Library of Australia) Retrieved 11 November 2011 Visibility was about ."No Negligence In Plane Crash" The West Australian – 26 August 1949, p.12 (National Library of Australia) Retrieved 11 November 2011 The aircraft climbed unusually quickly after it left the runway. It was observed to climb to a height of about and then roll and spiral vertically to the ground."Evidence At Guildford Air Crash Inquest" The West Australian – 23 August 1949, p.9 (National Library of Australia) Retrieved 11 November 2011"Ill-Fated DC3 Turned Over Backwards" The West Australian – 13 December 1949, p.8 (National Library of Australia) Retrieved 11 November 2011
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."Tangled Wreckage Of DC3 At Guildford" The Sunday Times – 3 July 1949, p.2 (1) (National Library of Australia) Retrieved 11 November 2011"Airliner In Flames After Crash" The Sunday Herald – 3 July, p.3 (National Library of Australia) Retrieved 11 November 2011 As a result of the aircraft diving vertically to the ground, the wreckage was mostly confined within an area that was no larger than . The aircraft narrowly missed the surrounding huts with wreckage coming to within of one hut, and within 5 paces of the front verandah of another. One propeller was found about from the wreckage.
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 laid a foam blanket around the burning wreckage and sprayed foam on the fire. 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."Tender Driver Fought Fire" The Sunday Times – 3 July 1949, p.2 (2) (National Library of Australia) Retrieved 11 November 2011
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 three 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. 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.
Investigation The Department of Civil Aviation immediately appointed a panel of two to investigate the accident. 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. 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.
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. 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.
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. 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. The investigation ended without determining the cause."Air Tragedy Inquiry" The West Australian 29 September 1949, p.16 (National Library of Australia) Retrieved 11 November 2011
Inquest In August 1949 the City Coroner, Pat Rodriguez, conducted an inquest into the deaths of the 18 people on board the aircraft.
A dispatch officer with MacRobertson Miller Aviation 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. Written evidence from the aerodrome control officer on duty in the control tower stated that he observed the aircraft turn through 180 degrees as though in a spiral turn or spin.
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.
A medical officer 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.
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.
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.
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. Justice Wolff of the Supreme Court of Western Australia was appointed to chair the inquiry. The inquiry commenced on 12 December 1949."Air Disaster Inquiry" The West Australian – 5 October 1949, p.24 (National Library of Australia) Retrieved 11 November 2011
Observations The inquiry received evidence from the aerodrome control officer on duty in the control tower at the time of the takeoff. 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 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 also saw the aircraft climb abruptly before it nosed over and twisted twice as it dived to the ground.
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. 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 of freight should be removed. Freight weighing was then removed. However, this employee believed the Load Sheet column labelled Index Units was not completed.
There were suggestions the aircraft had been incorrectly loaded with in the rear baggage locker when it was assumed only would be carried there."Loading Discussed Before Crash" The West Australian – 16 December 1949, p.12 (National Library of Australia) Retrieved 11 November 2011"Load Distribution In Crashed DC3" The West Australian – 15 December 1949, p.8 (National Library of Australia) Retrieved 11 November 2011 The accuracy of statements regarding was challenged.
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. The inquiry heard that all chocks were eventually accounted for."Chock Found On Tarmac After DC3 Crash" The West Australian – 14 December 1949, p.13 (National Library of Australia) Retrieved 11 November 2011 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.
Pilot competency