On May 22 2015, in good weather, Carlton Airlines, one of the oldest carriers in the industry, and piloted by industry veteran Michael Malthouse, crashed at Docklands, Melbourne. The repercussions would be disastrous for the airline’s management.
Eye witnesses reported seeing the aircraft plummeting to the ground, the crew seemingly unable to do anything. Investigators quickly arrived at the site and began sifting through the wreckage to try and establish what had caused the crash.
Initial suspicions pointed to terrorism or pilot error, because air traffic control report that the plane had suddenly flown off course, although closer inspection indicated that it had been veering of in a different direction since 2010.
There was a suggestion that it may have been shot down by a magpie heat-seeking missile fired by rebels in Collingwood, but investigators quickly ruled that out.
With those at the controls being the initial focus, attention turned to the cockpit voice recorder (CVR). The CVR records conversations between the pilot and his crew. Inspection revealed a calm environment, with chief pilot Malthouse and his crew almost resigned to their fate.
With the CVR failing to offer any explanation, investigators turned their attention to the flight data recorder, often called the black box. Once located in the wreckage the black box was sent to its manufacturer, Champion Data, to retrieve the contents.
The black box showed that a sudden drop in pressure was most likely the cause of the crash. In fact the recording of 35 tackles was dangerously low and investigators doubted that any airline could survive in such a low-pressure environment. A sudden drop in cabin pressure can lead to unconsciousness among the passengers and crew, leaving no one in control of the plane. Indeed this was consistent with what witnesses had reported on the night of the crash – a team full of unconscious passengers.
Investigators then turned their attention to what could have caused the drop in pressure – maintenance.
A forensic examination of maintenance records revealed an airline in disarray with an alarming neglect of aircraft maintenance. And anonymous source within the airline spoke to Team Crash Investigation:
“Management were solely focused on the short term, always looking to apply band aids rather than build long term sustainability and in that environment maintenance always gets it in the neck.”
The source went on to describe specifically how Carlton Airlines had gone from being a once-proud industry leader to a budget airline with a poor maintenance record.
“Eight years ago things were looking up. We acquired a Juddy, which at that time was the industry leader in turbo boosting the engine room. We were the envy of the industry.
“But moving parts eventually wear out and technology moves on. Our Juddy is basically being held together with string an sticky tape, while the rest of the industry has bought new technology into the engine room like the Fyfe jet booster, or the Gazza, although even the Gazza is showing signs now.
“Very few of the other parts we have acquired over the years have been any good. Most are now on the scrap heap. But it’s not just the engines, the front and tail sections have also been found wanting.
“At the tail end a failure of the rudder can be catastrophic but we have relied solely on an ageing Jamo. At the front we were actually doing OK a couple of years back but management decided to sell both our Betts and Waite forward thrusters. The Waite was always breaking down and no amount of maintenance was able to get consistent performance from it, so that can be justified, but the Betts was a prime piece of equipment.
“So management blundered there and then compounded the mistake by buying a Daisy outside receiver. The seller saw them coming big time. This was old technology when we got it and just hasn’t delivered.”
Carlton Airlines management scrambled to save their reputations by hinting that pilot error may have been to blame. After a strong public campaign to lay the blame at the feet of the pilot, the airline was rocked by the findings of the investigation.
The investigating panel handed down their three-volume findings and while acknowledging that the pilot had made some errors the report found that those errors were relatively minor. Instead the report found the airline management guilty of gross negligence in that they had created an environment in which a crash was inevitable.
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