Aviation safety investigations & reports

Engine power loss and departure from controlled flight involving Piper Seneca, VH-LCK near Broome Airport, WA on 11 July 2012

Investigation number:
AO-2012-093
Status: Completed
Investigation completed

Summary

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What happened

On 11 July 2012, the pilot of a Piper Seneca I, registered VH-LCK, was conducting a freight-carrying flight between Broome and Port Hedland, Western Australia. The flight was conducted at night under the instrument flight rules. Witnesses who heard or saw the aircraft take-off reported hearing unusual noises from the engines during the climb. Other witnesses closer to the accident site reported hearing the engine sound suddenly cut out before the aircraft banked left and descended steeply towards the ground. The aircraft wreckage was located amongst sand dunes, about 880 m beyond the upwind runway threshold. The aircraft was destroyed and the pilot sustained fatal injuries.

What the ATSB found

The take-off towards the ocean was conducted in dark night conditions with limited external visual cues. An on-board global positioning system (GPS) recorded a reducing ground speed as the aircraft approached and passed overhead the upwind runway threshold, but without a significant increase in climb performance. That reduction in ground speed occurred about the same time witnesses heard unusual noises from the aircraft’s engines.

In the absence of any identified environmental, airframe or structural factors, the witness reports and GPS data were consistent with the aircraft’s performance being affected by a reduction in engine power. Following the likely loss of engine power, the aircraft speed reduced significantly, resulting in uncontrolled flight, a steep descent and collision with terrain.

Although not identified as a factor contributing to this occurrence, post-accident examination of the aircraft’s fuel selector valves found the internal seals had deteriorated and allowed fuel to flow to the engines when the valves were in the OFF position. A review of the aircraft manufacturer’s maintenance instructions revealed this type of internal leakage may not be evident during routine maintenance, although a non-scheduled valve leak procedure was available.

What's been done as a result

The aircraft manufacturer has been advised that their maintenance instructions may not identify deteriorated fuel selector internal seals during routine maintenance. Airworthiness bulletin AWB 28-105, published by the Civil Aviation Safety Authority, recommended that owners and operators of Piper Seneca, and other aircraft fitted with similar fuel selector valves, regularly check their function.

Safety message

This accident highlights the need for pilots to closely monitor their aircraft’s airspeed and initial climb performance during take-off. The need for prompt identification of any performance degradation and optimisation of the aircraft’s available climb performance is emphasised. The accident also highlights the elevated risk associated with dark night conditions, which increase pilot workload, particularly in the case of abnormal aircraft operations.

The investigation also identified the potential for inadvertent operation of the engine magneto switches due to their close proximity to the landing and taxi lights and auxiliary fuel pumps, potentially increasing risk if these switches are operated at a critical stage of flight.

 

Download Final Report
[Download  PDF: 2.03MB]
 
 
 

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General details
Date: 11 July 2012   Investigation status: Completed  
Time: 2008 WST    
Location   (show map): near Broome   Investigation type: Occurrence Investigation  
State: Western Australia   Occurrence type: Loss of control  
Release date: 03 June 2014   Occurrence class: Operational  
Report status: Final   Occurrence category: Accident  
  Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-34-200  
Aircraft registration VH-LCK  
Serial number 34-7350236  
Type of operation Charter  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Broome International Airport, WA  
Destination Port Hedland, WA  
Last update 14 November 2018