Piper Aircraft Company designed the Chieftain with nose gear mounted landing lights

December - All aircraft in this category manufactured after 12 December 1986 to have safety belt and shoulder harness. Retrospective fitting for aircraft manufactured before this date is not required. MZK was manufactured in 1981

Whyalla Airlines operations manual for flight on single engine stated aircraft should land at nearest suitable aerodrome unless aircraft performs adequately on one engine in which case may proceed to aerodrome suitable for repairs

Whyalla Airlines operations manual in accordance with CASA CAO20.11 did not require life jackets to be carried if a flight was less than 50nm from land

June 29 - MZK operated by another pilot landed in a paddock. Pilots license was suspended by CASA

September 6 - Chief pilot involved in an air safety incident where he failed to comply with air traffic control instructions

September 21 - Chief pilot’s training and check approval and instrument rating suspended

October 27 – CASA brief to board questions chief pilot’s attitude towards safety and regulations

December 26 – Chief pilot has chief pilot approval cancelled. Replacement nominated however the original chief pilot continued to influence company operations

February 20 – CASA officers find three matters for show cause notice of AOC, management training and supervision to be deficient

May – Company required to establish a safety program including a safety officer that was not in a managerial position within the company

December 8 – Chief pilot has his training and check approval reinstated

1999 - 2000 – CASA Aviation Safety Surveillance Program surveillance activities for Whyalla Airlines were not carried out as expected due to CASA staffing levels

January – pilot commences employment with Whyalla Airlines

January – pilot trained to operate engines using company operations manual with EGT 50 degrees rich of peak

June 11 – pilot experienced landing gear problem on approach. After successful landing pilot was grounded by chief pilot due to a complaint about the emergency briefing. The pilot was reportedly told he would be terminated

August 4 – CASA respects the value of shoulder harnesses for all passenger seats

2000 – Pilots aware chief pilot was experimenting with lean of peak operations to reduce fuel usage. Whyalla Airlines average fuel flow was 140 lph with a target of 120 lph. Other operators average fuel flow was 160 lph

2000 – New pilot instructed to operate engine 50 degrees lean of peak

January 7 – left engine of MZK failed with accident pilot flying. Successful diversion ensued. Chief pilot was aggressive and abusive to pilot until he witnessed the damage

March 8 – last safety meeting before accident was held. Issues had turned from a focus on safety issues to general issues. Meeting frequency reduced since program inception and only three meetings held in previous 18 months due to high turnover of pilots

April 10 – manager approved to act as temporary chief pilot. Attitude to safety and compliance noted as factor

April 12 – Chief pilot was terminated. The manager resumes chief pilot responsibilities

May 9 – left engine magneto not working properly (49 hours and 63 flights before accident)

May 10 – right engine magneto servicing carried out after reports of engine “missing” at altitude

May – left hand engine crankshaft cracking due to metallurgical defect commences (approximately 50 flight cycles before accident)

May 31 – Manager assists pilot of MZK with departure and loading of aircraft. One witness thought there were signs of tension present

May 31 – refuelling truck arrived to refuel MZK. Witness accounts suggest uncertainty over whether MZK was refuelled. Fuel truck consolidation confirmed it was indeed refuelled

May 31 1823 – aircraft departs Adelaide. Propellor RPM2400 – the usual climb RPM

May 31 1833 – aircraft reaches top of climb and cruise speed 183kts. Propellor RPM2200 – the usual cruise RPM

May 31 1845 – pilot reduces power on right hand engine due to rough running

May 31 1847 – aircraft diverges 19 degrees right of track combined with a significant speed reduction (177kts to 167kts). Left propellor increased to 2400RPM

May 31 1852 – aircraft drifts right of track before correcting towards GIBON

May 31 1858 – left hand engine crankshaft fails catastrophically (engine failure) due to change in crankshaft loads when reducing power for descent

May 31 1859 – right hand engine power is increased to compensate for left hand engine failure. Power increase likely well above normal cruise power causing detonation

May 31 1900 – right hand engine loses significant power due to holing of number 6 piston

May 31 1901 – aircraft transmits mayday call reporting both engines failed

May 31 1904 – right hand engine fails completely (propellor not feathered due to close proximity to impact and high pilot workload controlling the aircraft)

May 31 1905 – pilot has zero visibility from ambient light or landing lights due to the landing lights being attached to the nose landing gear and the landing gear being retracted

May 31 1905 – aircraft impacts the water in a slightly right wing low angle (likely due to increased drag from the right propellor not being feathered)

June 1 1241 – bodies of two occupants were recovered from the water. A third was seen but not recovered

June 1 – Managing director of Whyalla Airlines suspends all flight operations

June 2-6 – anonymous reports to CASA outlined concerns about relationship of chief pilot and company pilots

June 6 – CASA interviewed company pilots finding fuel contents were sometimes not checked, chief pilot’s workload was excessive and he over-rode former chief pilot, accuracy of flight and duty times were uncertain, turn around times on RPT routes were too short and Chief pilot put pressure on pilots at the detriment of safety

June 6-13 – CASA undertakes special audit. Findings were chief pilot monitoring insufficient, high flight hours by chief pilot, company did not have sufficient pilots due to high flight ours from chief pilot meaning it was in breach of the Civil Aviation Act 1998

June – Investigation of the safety culture showed the Manager considered safety meetings a waste of time. Fast turn around times and high workload, while discussed, were never addressed at an operational level. Management feedback on safety incidents was poor and inconsistent. Manager did not actively participate in safety meetings

June – Investigation of operational safety culture showed the manager was not addressing operational safety issues although they were raised in meetings. The manager intended to influence pilots in a way that was potentially detrimental to flight safety. Occasionally he became abusive and used fuel consumption as an indicator of pilot ability rather than safety awareness

June – The investigation revealed a high level of pilot turnover with 5 of 6 pilots leaving and being replaced. The accident pilot and one other were the longest serving pilots. Although pilot turnover is not unusual, this number was high for this type of operation suggesting a poor safety culture may be present

June 10 – CASA suspends Whyalla Airlines AOC pending investigation of concerns of anonymous pilot complaints

June – The refuelling organisation revised procedures nationally for communicating fuel grade and quantity to pilots and required documentation evidence of such

October – ATSB issues safety recommendations pertaining to the use of applying anti-galling compounds and certification requirements of piston engines operating conditions under which combustion chamber deposits that may cause pre ignition are found

October – ATSB issues safety recommendations that require CASA to educate industry on ditching procedures and techniques that will maximise chance of survival

October – ATSB issues safety recommendation and CASA amends Civil Aviation Orders to require aircraft carrying fare paying passengers over water to carry life jackets for occupants

November 9 – Special Advisory Bulletin was issued noting material defects in the crankshafts of Textron Lycoming engines

October 8 – CASA advise a draft paper was prepared proposing shoulder harnesses be required in all seats occupied for takeoff and landing. Such harnesses are still not enforced

December 14 – an identical engine to MZK’s left engine failed due to crankshaft failure

February 1 – Textron Lycoming recalled engines including an identical engine fitted to MZK due to material defects in the crankshaft

July 22 – August 5 – commensurate with issues raised by CASA in June 2000, factors that were inconsistent with aviation safety and may have been relevant to the accident were investigated

September 16 – Textron Lycoming recalled more engines including the left hand engine that was fitted to MZK due to material defects in the crankshaft

Altimeter capable of a calibrated accuracy of 60ft (Air Services Australia 2022, 1.7-1

May 30 - inexperienced pilot documents running right engine to 50 degree lean of peak to the point of detonation