Case Study 2: Investigation Methods - Beechcraft King Air Analysis

This case study analyzes the investigation of the Beech Super King Air 200 aircraft crash, also known as the “Ghost Flight” incident, which occurred in 2000. The investigation, conducted by the Australian Transport Safety Bureau (ATSB), aimed to determine the cause of the accident and involved examining various factors, including pilot training, weather conditions, aircraft systems, and evidence related to the pilot's and passengers' incapacitation. The investigation focused on evidence such as witness statements, oxygen system maintenance records, and weight and balance calculations. The primary conclusion of the investigation was that the incapacitation of the pilot and passengers was most likely due to hypobaric hypoxia resulting from partial or complete aircraft depressurization and lack of supplemental oxygen. The study also emphasizes the importance of evidence preservation and the limitations caused by the absence of flight recording systems. The case study highlights the ATSB's role in aviation safety investigations and the importance of thorough evidence analysis in determining the causes of aviation accidents and preventing similar incidents in the future. The investigation also suggests that an aural warning system for high cabin altitude could have prevented the accident.

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Contents
Introduction...................................................................................................................................3
Investigation Legal Context............................................................................................................4
ATSB...........................................................................................................................................4
Investigation Conducted............................................................................................................5
Using Evidence in Investigation.....................................................................................................7
Background................................................................................................................................ 7
Case Study................................................................................................................................. 8
Effectiveness of the Investigation................................................................................................11
Conclusion................................................................................................................................... 13
References................................................................................................................................... 15

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Introduction
A Beech Super King Air 200 aircraft, departed from Western Australia’s Perth at 1009 UTC, on
September 04th, 2000 on a charter flight to Leonara with seven passengers on board with one
pilot (Griffioen, 2009; Klan, 2017). Till 1032, the operations and communications of the aircraft
with the pilot all seemed to be normal. Though, after a very short while of the aircraft climbing
through the altitude which was assigned, the speech of the pilot became majorly impaired and
he was not able to respond to the instructions of the ATS. There was a progressive
deterioration of the pilot over the next eight minutes which was revealed through the open
microphone transmissions and the pilot became unconscious; and there was also an absence of
any sort of sounds of the passenger activity from the aircraft (Australian Transport Safety
Bureau, 2014). For the remainder of the flight, no human response of any sort could be
detected. After five hours of take off from Western Australia’s Perth, the aircraft came in
contact with ground near Queensland’s Burketown and was completely destroyed with no
survivors (International Aviation Safety Association, 2017).
The crash resulted in an investigation being conducted into the accident which was referred to
as “Ghost Flight” (Thomas, 2011). The purpose of conducting this investigation was to establish
if the accident was caused due to negligence or for any other reasons and to evaluate the
reason behind this accident. In the following parts, the investigation conducted in this context
has been evaluated whereby the evidence used in this investigation, along with the
effectiveness of the conducted investigation has been elucidated.

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Investigation Legal Context
ATSB
The ATSB, i.e., the Australian Transport Safety Bureau is an operational autonomous multi-
modal Bureau which comes within the “Commonwealth Department of Transport and Regional
Services” (Australian Transport Safety Bureau, 2017a). The safety investigations conducted by
ATSB are independent of the operator, regulatory or the other external bodies. Through the
Director of Air Safety Investigation, in terms of aviation, the ATSB has been given the
responsibility for the investigation of accidents, incidents, safety deficiencies and serious
accidents which involve the operations of civil aircraft in the nation, and it also participates in
the overseas investigations of serious incidents and accidents where the Australian registered
aircrafts are involved (Skybrary, 2017). The investigations are not the only thing conducted by
the ATSB as it also studies the aviation systems for identification of the underlying factors and
the trends which have the possibility of adversely affecting the safety (Revolvy, 2017). The basic
concern here is for the safety of the commercial air transport and a specific emphasis is made
to the fare paying passenger operations (Australian Transport Safety Bureau, 2000).
The aviation functions are performed by the ATSB as per the provisions covered under Part 2A
of the Air Navigation Act, 1920 (Austlii, 2017). Under section 19CA, of this act, the investigations
are conducted with the object of determining the situations which surround the accidents,
safety deficiency, serious incident or incident for prevention of occurrences of similar events
(Federal Register of Legislation, 2008). This determination results in the formation of the base
for the advisory notices, safety recommendations, accident prevention programs, safety

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studies, research and statistical analysis. The objective of these investigations is not to
determine the liability or the blame. Though, the investigation is required to include the factual
material having the required weightage for supporting the analysis and the conclusion which
has been attained. At times, this material shows the information which reflects on the
individual’s and the organization’s performance and the actions contribution in the outcomes of
the issue in investigation. This material is used in a balanced manner where a proper
explanation is given to what took place and the reasons for the same, in an unbiased and fair
way (Australian Transport Safety Bureau, 2017b).
Investigation Conducted
In this case, the investigation which was conducted showed that the pilot had the proper
license and had also gone through the required training. Further, there was nothing to show
that the pilot had been medically unfit for operating the flight. The investigation also examined
the weather and it was established that there was no hazard presented by the weather
regarding the operation of the aircraft and it was on its planned route as well, where
throughout, there was no such hazard owing to weather as a factor. The flight path of the
aircraft had been consistent with the manner in which the aircraft would have been if
controlled by the autopilot where there was no human intervention, once the position DEBRA
was passed by the aircraft (Aviation Safety Network, 2017). Once the aircraft had attained the
altitude of FL250, which was the assigned altitude, the problems with the pilot in his speech
and breathing patters were shown to be constantly changing and there was a presence of
consistent sign with hypoxia; however, an explosive or rapid depressurisation of the aircraft

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cabin was not likely to have taken place in this instance (Australian Transport Safety Bureau,
2000).
When the testing was conducted, it was revealed that Hydrogen Cyanide and Carbon Monoxide
were not very likely to have been the factors in occurrence of this accident and there was also
an absence of any kind of irritation in the occupants’ airways which was a proof of the fact that
the chances of dire in the cabin was an unlikely affair. The chances of the pilot being
incapacitated by being alone, as a result of some medical ailment like heart attack or stroke was
also an unlikely possibility as there was an absence of an apparent activity or of an action by the
other occupants of the aircraft during the flight duration (Australian Transport Safety Bureau,
2000).
It was concluded in the investigation that even though there could have been a number of
possible reasons for the incapacitation of the passengers and the pilot, the incapacitation was,
most likely, a result of the hypobaric hypoxia as a result of the aircraft being partially or wholly
unpressurised, along with the fact that the supplemental oxygen was not received on time. As a
result of the major and extensive nature of the damages which the aircraft attained, which was
due to the impact of the aircraft with the ground, nothing could be salvaged from the aircraft.
Further, the lack of recording systems being installed in the aircraft resulted in the non
determination of the reasons for which the aircraft was unpressurised or why the passengers
and the pilot was unable to get the supply of supplemental oxygen could not be determined by
the conducted investigation (Australian Transport Safety Bureau, 2000). Though, the
investigation did conclude that an aural warning regarding the high cabin altitude could have

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prevented the accident, along with setting up of the aural and visual alerts for operating when
the cabin pressure altitude went beyond 10,000 ft (Aviation Chief, 2017)
Using Evidence in Investigation
Background
Evidence denotes something which is presented for supporting an assertion that has been
made, and can be strong or weak. Something which can directly proof the assertion being true,
without raising any counter points is the strong kind of evidence. And something which is just
consistent with the assertion that has been made, but is unable to rule other the contradictory
assertion is deemed as circumstantial evidence. The evidence in any investigation is a crucial
aspect for proving a point which has been made. The investigators of any incident are required
to take special care in collecting all the evidence and evaluating them properly. There is a need
to protect the evidence from being tampered, being lost, washed away or be contaminated. So,
while preparing for any investigation, the investigator has to be prepared beforehand and
evaluate every piece of evidence with care (Australian Transport Safety Bureau, 2000).
At the scene of the evidence, there are two key points which have to be taken care of, i.e.,
preservation of evidence and continuity of it. The preservation of evidence relates to making
certain that the evidence which is collected, is not lost, degraded, contaminated or alerted. The
continuity of evidence relates to being able to establish that a particular evidence item, which
had been examined, exhibited or analysed before the court was the same one as was collected
from the accident site and that the same has not been changed at all. Evidence is something

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which can be lost over a period of time due to a number of factors. So, one has to follow the
golden rule of “always collect the evidence at the earliest possible opportunity”. If this is not
done, one can risk not getting any evidence at all. There is a key need to protect the evidence
from different elements both after and before collection, and secure and store it at the earliest.
Particularly when dealing with perishable item, it needs to be put in evidence at the earliest and
even refrigerate in needful cases. The key here is to protect the evidence from tampering. The
emergency response teams have to take special care, whereby even though their work takes
significance over evidence collection, they do not contaminate the evidence in a wilful manner.
Case Study
The investigation into the Beech super King Air 200 VH-SKC was conducted by ATSB. In
conducting this investigation, a lot of factors were taken into consideration and the presented
evidence was evaluated to understand what actually went down in this case. And the evidence
or the absence of it per se, resulted in the conclusions being drawn for this investigation. It was
ensured in this investigation that the evidence was not tampered with and that each piece of
evidence was collected with care and in a swift manner. The first point which was investigated
upon here was the professional approach of the pilot to flying and whether he had been
methodical in using the checklists. In this regard, the witnesses were taken as the evidence who
stated that the pilot had been happy and physically fit before he took off for the flight. This led
to the investigation concluded that the pilot had been medically fit as there was no evidence to
show otherwise or to show that fatigue of pilot resulted in the accident (Australian Transport
Safety Bureau, 2000).

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Another factor which was evaluated in this case was the contents of the aircraft oxygen system.
In this regard, the evidence highlighted that the oxygen bottle had been removed from the
aircraft back in May 2000 and the same had been tested hydrostatically at the facility where it
was pressure of the vessel was tested and where it was refilled. Subsequently, it was installed
again in the aircraft. The documents of the aircraft clearly highlighted that the oxygen contents
had been properly replenished an entire month before the accident took place. Though, the
investigation could not give confirmation to whether the gas which was filled in the oxygen
system of the aircraft was as per the specifications of the dry breathing oxygen for aviators.
Though, there was also an absence of evidence which could show that the required
specification was not met. As per the witnesses, the oxygen pressure gauge, at the date of
accident, showed 1,500 lb/in, which was a sufficient amount of oxygen for the passengers and
pilot for 33 minutes in case of depressurisation (Australian Transport Safety Bureau, 2000).
Another key piece of evidence which was evaluated in this case was weight and balance. In
considering this, the personal baggage and the weight of eight occupants was taken into
consideration. It was assumed that the occupants remained seated and the centre of gravity
was calculated to be within the range of flight as was allowed. After taking into consideration all
of the factors, there was no evidence before the ATSB which could show that there was any
dangerous good on the aircraft during the time of the flight which could have resulted in the
incident. When the records of the maintenance of the aircraft were evaluated, no recurring
problems in maintenance were found which could be deemed as a factor in the incident which
occurred. The maintenance manual of the manufacturer did not cover a need for performing
ongoing functional tests of the barometric switches which had been activated for altering

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regarding the cabin altitude and about to automatic passenger oxygen systems. The
investigation could not find any evidence regarding the testing or changing of these switches
since the year of 1990. Due to these reasons, the serviceability of these barometric switches
could not be determined (Australian Transport Safety Bureau, 2000).
The evidence presented for the examination of the landing gear had been consistent with the
same being in a retracted position when the collision took place. The investigation also could
not find any evidence which could show that something other than the normal operations
regarding the flight controls were underway at the time the accident took place. When the
engine and the propellers were investigated, the evidence highlighted that there was rotational
damage on both the power turbine assemblies and the compressor which highlighted that both
of these sections of the free turbine engine were turning when the impact occurred. There was
also presence of evidence which showed that there was a pre-existing leak of bleed air at the
P3 customer air outlet of each engine through the gaskets. Though, these leaks were deemed
as not a factor in the accident. When the damage to engines and propellers were examined,
along with the ground scars, the evidence revealed that both the engines were operating at the
time of ground impact and were also developing power. Regarding the claims of fire, the
statements of the eyewitnesses revealed that there had been no sign of fire till the aircraft had
collided with the ground and only after was a fireball visible. Even though the ground fire
continued for several hours after the impact, there was no evidence to show that there had
been a fire before the impact. These are just a few examples of the evidences which helped the
ATSB in their investigation (Australian Transport Safety Bureau, 2000).

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Effectiveness of the Investigation
The key purpose of any investigation is to gather the facts so that the complaint can be resolved
and the situation can be clearly explained. This is also important as at a later date, some
attorney or jury could scrutinize a particular aspect of the investigation which was conducted.
For instance, the very case which is being discussed here could have to be evaluated again if a
claim by some person is made in the future stating that they have evidence to prove the actual
reason of the accident or any other claim. At that point of time, the effectiveness of the
investigation conducted in this case would help in establishing the truth. And it could mean the
new claim being proved true or false, in context of the originally conducted investigation (Wood
and Sweginnis, 2006).
At times, the job of a person or their wellbeing could be dependent on the quality of
investigation. For instance, had the investigation of this case not been conducted in a proper
manner, it could have stated that it was the fault of the pilot for the plane hitting the ground,
whereas the reality is quite different and it was not the fault of the pilot. Hence investigation
cannot be conducted in a haphazardly manner or in absence of a clear plan in mind. As the
memory of the investigators cannot remember every point established during the investigation,
the conduct and documenting of the investigation in a proper manner becomes all the more
important (Rodríguez-Pérez, 2016).
For any investigation to be effective, there is a need to minimize the intimidation of the
witnesses, for the investigation teams to be properly formed and duties being divided in them,
for establishing a proper time frame of the investigation so that it could be conducted in a time

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based manner, determining if there is a need to provide a confirmatory memorandum,
obtaining all the required documents, planning for the interviews which have to be conducted,
preparing both closing and opening comments, preparing set of written questions, taking care
when the multiple interviews are conducted, issuing written statements, and taking clear and
proper notes (Thompson, 2007).
The effectiveness of an investigation also depends upon the continuity of evidence, whereby
not only the evidence must be properly preserved, but a chain of custody should be maintained
to show that the same has not been altered after it was collected. There is a need to keep
unbroken and auditable record for the security of every evidence item. In this chain, it needs to
be shown how, where and when the particular evidence was collected and stored; how it was
handled; every person who handled it, signed for handling the evidence; and there were no
gaps in the records. In case this chance is broken, the evidence loses its value and effectiveness
of the investigation is threatened. At the sites of accidents thus, a proper plan is formulated to
collect and handle evidence and standard tool kits are used, so that the evidence can be
collected in a proper manner. In aircraft related accidents, the primary and secondary scene,
both have to be carefully evaluated. In this regard, there is a need to follow SMEAC format,
where situation, mission, execution, administration and communications have to be
considered.
In order for the investigation conducted by ATSB to be effective, it had to take into
consideration a number of factors which were related to the accident and the two major
factors which were investigated here was the probability of the aircraft being unpressurized for