On 2 July 1949 a Douglas DC-3 aircraft departed from Perth Airport for a night flight of 817 kilometres (507 mi) to Carnarvon.
The aircraft climbed to a height of about 150 metres (500 ft) and then spiralled almost vertically to the ground, killing all 18 people on board.
[3][18][19] After sunrise, police, firemen and undertakers worked for an hour to remove the bodies of the 18 people killed in the accident.
[10] 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.
[i][20] 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.
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.
[8]: 114 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.
[8]: 115 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.
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.
[8]: 114 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.
[21] 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 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.
[23][8]: 116 In August 1949 the City Coroner, Pat Rodriguez, conducted an inquest into the deaths of the 18 people on board the aircraft.
[12] 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.
[12] 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.
[n][12] 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.
[t] Captain Cyril Kleinig, an approved checking pilot with MacRobertson Miller Aviation, gave evidence to the inquiry.
[u][12][30] A pilot who had flown the Fitzroy to Carnarvon and return the day before the accident told the inquiry the aircraft had behaved normally.
[w][13][28] The superintendent of air navigation and safety in the western region of the Department of Civil Aviation[x] said the bodies of the pilot and first officer were found in their correct seats in the cockpit.
Particular attention was paid to the body found closest to the rear of the cabin, a few feet (a metre) forward of the hostess's seat.
[z][27] Mr Winneke suggested to the inquiry that the immediate cause of the accident was that the pilot lost flying control of the aircraft.
[27] The report and findings of the inquiry were not released until 8 March 1950 when the new Minister for Civil Aviation,[ab] Thomas White, tabled them in the House of Representatives.
[33][34] The inquiry acknowledged that the operator, MacRobertson Miller Aviation, had distributed instructions about aircraft loading to its pilots on 30 June but considered more should have been done.
He also cited the hardship that would be inflicted on many remote communities in Western Australia if the operator's airline licence were to be suspended or cancelled.
[9] In July 1946, it was acquired by MacRobertson Miller Aviation and ferried from the Philippines to Perth, where it was converted from a military C-47 to a civil DC-3 with seating for 21 passengers.