The very best intentions

1527
Illustration: Juanita Franzi | Aero Illustrations

Avro Lincoln, Mk 31, A73-64
Mt Superbus, Qld
4.14 am, 9 April 1955

A sick baby, a tired crew, a mountain waiting in the mist

Ten years of peace had made RAAF Townsville a relaxed place by military standards. The base had shrunk from its wartime size and was the spacious home to a single squadron.

Number 10 Maritime Reconnaissance Squadron flew Avro Lincolns from the recently extended runways on patrols over the Coral Sea and northern Australia. These duties were occasionally intensive, but predictable. Peter Finlay, who lived on the base with his parents, remembers how on sunny tropical weekend mornings, officers would requisition the brightly painted ‘Follow me’ Jeep from the tower and use it to collect newspapers from the nearby town.

The situation was not quite as pleasant in the maintenance hangars, where keeping the squadron airworthy was a continual struggle. By Easter 1955, only one Lincoln was airworthy, the rest having been grounded by ‘a backlog of inspections and the unavailability of spares’.

Regardless, Good Friday, 8 April 1955, was a slow day, with much of the squadron establishment on leave or stood down. A duty crew was rostered for search and rescue with the squadron’s one serviceable Lincoln, but had an easy shift until 10.30 pm when the superintendent of Townsville Hospital phoned with a request to take a two‑day-old baby girl to Brisbane. She would die if not given a blood transfusion within 12 hours.

The squadron’s commanding officer, Wing Commander John Costello, had been having dinner with his visiting parents. He decided to make the flight himself, and stood down the duty pilot, Sergeant Reed. Like many of the squadron’s aircrew, Costello was a World War II veteran. He had flown Short Sunderlands with 10 Squadron in the Battle of the Atlantic, and had fought off a shark while awaiting rescue after a crash in warmer waters.

The navigator was Peter’s father, Squadron Leader John ‘Jack’ Finlay, a World War II and Korean War veteran who had recently returned from an advanced polar navigation course in Britain with the Royal Air Force. ‘He was given his squadron leader wings and was effectively 2IC of the squadron,’ Finlay says. He thinks his father may have been attempting to bring newer and higher standards of navigation accuracy to 10 Squadron. ‘My mother used to say, “You’d think from the reaction, we were introducing witchcraft”,’ Finlay says, but he doesn’t think there was any underlying tension between his father and the other officers. ‘He was hale-fellow-well-met and got on well with most people.’

Radio operator Flight Lieutenant William Cater was a veteran of the air war in New Guinea. The co-pilot, Squadron Leader Charles Mason, had saved a pilot from the burning wreckage of a Bell Airacobra during the war.

Mafalda Gray, a nurse who had recently resigned from Townsville Hospital to move to Brisbane, volunteered to accompany the baby, whose name was Robyn Huxley, and the Lincoln took off at 12.30 am on 9 April, bound for Eagle Farm Airport in Brisbane. Thanks to countless war movies and flypasts, it’s an easy scene for modern readers to imagine because the Lincoln was a development of the wartime Lancaster bomber—four Rolls-Royce Merlin engines bellowing into the night, but on a flight of mercy, not destruction.

Because of the need to keep the baby warm and avoid her becoming even more hypoxic, the flight climbed no higher than 6000 feet. An oxygen bottle had been temporarily fitted in front of the pilot’s position in the ‘long nose’ Lincoln’s extended crew compartment where she was travelling. The flight plan was a direct course to Brisbane.

Shortly after 4 am, Costello called on VHF to Brisbane Control. ‘Estimating Brisbane in about 10 minutes. May we let down from 6000 feet to 5000 feet? We are in cloud at the moment.’

Brisbane Control replied, ‘Cleared to 5000 feet, or 4000 if you wish … ’

A further transmission from Brisbane to ‘report sighting Caboolture’ was acknowledged by ‘Roger Roger, will do’. Nothing more was heard from the aircraft.

About 4 am, two members of a party of bushwalkers near Mount Superbus in the Border Ranges near the NSW/Queensland border, woke to the sound of light rain on canvas. A few minutes later they heard an aircraft low overhead, which ceased suddenly with a crash. One of them noted the time as 4.14 am. Other members of the group heard the noise and searched outside but could see nothing. At 4.27 am, they heard two explosions in quick succession. A bushwalker retrieved his car and by 7.45 am had phoned the RAAF base at Amberley. By 9 am bushwalkers had spotted aircraft wreckage near the peak of Superbus. A RAAF Canberra confirmed the location soon after. Later that day it was confirmed that everyone on the aircraft had been killed.

Finlay, 12 in 1955, remembers how a clergyman approached the house on Easter Saturday to announce the Lincoln was missing, and how his mother burst into tears before a word was spoken. ‘It was exactly like the scene in the film The Right Stuff, where the sombre man in black comes up the driveway, I shiver when I see it now.’ His other, slightly bizarre, memory of the day is of being packed off with his siblings and the Costello children to the Wintergarden cinema to watch The Creature from the Black Lagoon. When he came back, he was told his father was dead.

Like thousands of crashes before and since, the destruction of A73‑64 was a controlled flight into terrain. The aircraft had been south and west of its planned flightpath and hit the mountain wings level, less than 200 feet from the peak. The throttles, one of few identifiable pieces of wreckage, were forward, suggesting the aircraft was attempting to climb.

Soon after the crash, it emerged the Lincoln had flown orbits over the town of Bell in south-east Queensland. Bell is about the same latitude as Caboolture, 80 km east, or the crew may have mistaken it for Gympie, to the north.

‘When a pilot does an orbit, it means they are confused,’ Finlay says. ‘Clearly at Bell, they were unsure of their position. In fact, they started getting off course almost from the very beginning.’

The key question was why such an experienced and distinguished crew had allowed such an error. Of Jack Finlay, the RAAF Director of Flying Safety’s ‘crash critique’—a report prepared for the service court of inquiry—said, ‘His assessments over a number of years were above average and he was considered an excellent crew member and very keen.’

Weather had been against them. The critique describes fine weather and an 11,000 feet cloud base at the beginning of the flight. At its end, there had been 8 oktas stratus at 3000 feet in the Border Ranges, although the weather was better in Brisbane. Winds over the route had been slightly more easterly than forecast which, if not corrected, could have blown the aircraft to the west. And ‘the route over which the aircraft flew did not have any towns that could be reliably pinpointed,’ in the words of the critique, which also suggested the baby’s oxygen bottle may have affected the magnetic compass.

The critique also found that the navigator’s compass had not been swung and the direction-finding loops on Lincolns were notoriously unreliable. And the aircraft had not carried equipment for an instrument approach to Eagle Farm. ‘The flight plan, however, would have led air traffic authorities to believe that the reverse was the case, as an incorrect entry to the effect that a radio compass was carried was included in the A.177 (form),’ the critique says.

Reading the critique 65 years later, in the context of modern organisational safety thinking, it is striking how it comes to a similarly contextual conclusion. Reading between the lines, it seems senior RAAF officers had no illusions as to how the crash reflected poorly on the squadron and the service, and had taken care to share responsibility around.

‘It appears that the exact cause of the accident will never be revealed,’ it said, ‘but …. it is disturbing to note the number of irregularities, of greater or lesser degree, which have occurred in relation to the preparation of aircraft, flight planning and the conduct of the flight.’

The critique lists 10 conclusions.

It is concluded that this accident resulted from faulty navigation and that the factors which contributed to the faulty navigation were:

  • weather
  • lack of lights en route on which to pinpoint or take drifts
  • loop unreliability
  • compass errors

The report listed five other contributing factors:

  • the incentive to carry out the task quickly
  • the unavailability of any other aircraft to carry out the flight
  • the lack of radar aids
  • the suggestion to let down to 4000 feet
  • non-observance of orders.

Peter Finlay obtained a commercial pilot’s licence, with a twin rating. ‘I went on to enjoy aviation,’ he says. ‘You do what you do and what happened is over and done with. History isn’t necessarily going to repeat. I was a racing driver as well, which must have frightened my poor mother.’

Flight Safety Australia contributor Adrian Park’s other job is director of safety, human factors and culture, at Toll Aeromedical. He makes no judgement on whether the Lincoln should have taken off that night but notes the crew lacked decision aids that have since become part of emergency medical service (EMS) aviation protocol.

‘We have two golden rules: first, don’t become part of the problem and secondly, always balance risk against return,’ Park says. ‘The Lincoln crew didn’t have a risk management language or process, although I’m sure they thought about it.’

Modern EMS go/no-go decisions are informed by background information such as a US study that found only 11 of every 1000 EMS flights were vital for the immediate survival of the patient. (Moront, Gotschall, Eichelberger, 1996)

‘One of my first EMS instructors would say, “There is always another way.” That surprised me at first, but he was right,’ Park says, noting that with a critical window of 12 hours, the baby would be a priority three patient on the system used in modern EMS, where priority one is hospital treatment within an hour.

At Toll, and most other operators, only priority one jobs are flown after midnight, due to the increased risk involved with circadian challenge operations (CCO). ‘And if there’s any sort of weather concern after midnight, we don’t go,’ he says. The Lincoln crew had been awake for about 16 to 17 hours when they took off, and most likely about 20 to 21 hours at the time of the crash, which occurred in the mid-point of what modern fatigue management practice calls the window of circadian low. This is the time when pressure to sleep is strongest and performance is most reduced, even among people habituated to night shift. It is a witching hour of microsleeps and errors.

A modern crew on day shift would have been past their duty limit hours before the take-off, Park says.

He also notes how modern EMS pilots are never told the nature of the emergency. ‘The idea is that you focus purely on the mission—either you can do it or you can’t.’

Hindsight is a luxury to be used sparingly, and never in judgement, Park says, but with developed risk management tools, a take-off several hours later with a rested crew could have delivered the baby to Brisbane within the 12-hour period, with a daylight arrival.

Finlay says the message of the crash is easily seen—with 20/20 hindsight. ‘Recognise when things are going wrong, and find an escape route,’ he says.

‘In hindsight, that would have saved everyone, but in fact there was probably a strong variant of get‑there‑itis and difficulty in recognising how, what we now call holes in the Swiss cheese, were lining up.’

There was probably a strong variant of get‑there-itis and difficulty in recognising how, what we now call holes in the Swiss cheese, were lining up.

image: Avro Lincoln bomber | © Lisa Owen

Those who remained

Sergeant Alan Reed, the national serviceman who Squadron leader Costello had bumped from the flight, stayed in the RAAF. He retired as Air Vice-Marshal Reed in 1990. Costello had offered him a place on the Lincoln but he had declined, preferring to sleep in a bed than a noisy fuselage. ‘If he’d been in the aeroplane assisting, you never know what he might have told the commanding officer,’ Finlay says. ‘But realistically, in those days a junior sergeant pilot was never going to even think of telling a wing commander, “Sir, you’re wrong.” That sort of thing is easier today, and encouraged.’

The wreck of A73-64 remains on Mount Superbus where it has become the focus of a challenging bushwalk. A RAAF roundel can still be seen on the rear fuselage, and the bent crankshaft of one of the Merlin engines is a witness to the force of the crash. Peter Finlay climbed Superbus in 1988 with his brother Warwick and three of their sons. At first they surveyed the bent alloy and the scratched-on initials of previous pilgrims dispassionately. But soon after, as Peter recited John Gillespie Magee’s High Flight, emotion returned—pride, grief and wondering what might have been. As they descended, they felt a sense of peace, despite the arduous trek.

1 COMMENT

  1. Wow, instrument flying has so much to it. A pilot needs to be very aware of the weather, aircraft performance, pilot limits, mission of the flight, human performance, navigation aids and instruments. Now I understand why the initial twin IF training is amongst the toughest pilot training stages of a pilot’s career.

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