At about 1440 Eastern Daylight-saving Time on 22 January 2013, the pilot of a Cessna U206F amphibious aircraft, registered VH-UBI, was conducting a seaplane joy flight from Corio Bay, Victoria with two passengers on board. During the flight the pilot refuelled the aircraft at Barwon Heads Airport, necessitating the use of the landing wheels. On the return trip the pilot detoured for local sightseeing before heading back to Corio Bay for a water landing. On touchdown, the aircraft pitched over and came to rest inverted. The pilot assisted the two passengers to evacuate the aircraft before rescue vessels arrived. All three occupants sustained minor injuries. The aircraft was substantially damaged.
What the ATSB found
The ATSB found that the pilot was distracted during the departure from Barwon Heads and as a result did not retract the landing wheels during the after take-off checks. The investigation also determined that on returning to Corio Bay, the pilot shortened the approach due to perceived time pressure and did not complete the normal downwind and short final checks. In not completing those checks, the pilot reduced the likelihood of identifying that the landing wheels were still extended. Such events where individuals forget to carry out an action due to distractions are not uncommon and are described as skill-based lapses.
This accident is a reminder for pilots and operators that human error can occur at any time, and highlights the importance of managing operational pressures and avoiding distractions. The need to follow procedures and complete checklists diligently is also reinforced. Effective application of threat and error, and distraction management principles can reduce risk.
The operator’s requirement for passengers to wear life jackets throughout the flight enhanced the survivability of the passengers.
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|Date:||22 January 2013||Investigation status:||Completed|
|Time:||1540 EDT||Investigation level:||Defined - click for an explanation of investigation levels|
|State:||Victoria||Occurrence type:||Incorrect configuration|
|Release date:||04 December 2013||Occurrence class:||Operational|
|Report status:||Final||Occurrence category:||Accident|
|Highest injury level:||Minor|
|Aircraft manufacturer||Cessna Aircraft Company|
|Type of operation||Charter|
|Damage to aircraft||Substantial|
|Departure point||Barwon Heads Airport, Vic.|
|Destination||Corio Bay, Vic.|