Aviation safety investigations & reports

Departure from controlled flight and collision with terrain involving Ayres Corporation S2R Thrush, VH-JAY, 17 km SE of Hyden, WA, 18 October 2013

Investigation number:
AO-2013-183
Status: Completed
Investigation completed

Summary

Download Final Report
[Download  PDF: 2.42MB]
 

What happened

On 18 October 2013, the pilot of an Ayres Corporation S2R Thrush, registered VH-JAY, was conducting aerial agricultural spraying activities on a property near Hyden, Western Australia. At about 1330, following the completion of a number of spray runs and a break for lunch, the pilot departed to complete further spraying. Following the failure of the aircraft to return, a search was initiated. The aircraft wreckage was found a short time later about 1,700 m from the departure airstrip. The aircraft was destroyed and the pilot was fatally injured.

What the ATSB found

The ATSB found that the aircraft departed controlled flight from which the pilot was unable to recover, leading to the collision with terrain. On the basis of the available evidence, it was not possible to determine the reasons for the loss of control.

The ATSB identified two aspects of the aircraft’s operation which had the potential to adversely affect safety. These were the use of an unapproved fuel mix and operation of the aircraft above its published maximum take-off weight.

Safety message

Operators and pilots are reminded of the dangers of operating aircraft engines on an unapproved fuel mix as this increases the likelihood of engine damage which could affect the safety of operations. Pilots and operators are also reminded of the need to adhere to an aircraft’s maximum take-off weight to ensure the on-going safety of the aircraft and operations.

Download Final Report
[Download  PDF: 2.42MB]
 
 
 

Photos

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Inquest

ATSB response to Findings

The Coroner’s Court of Western Australia (WA), without holding an inquest, recently made findings into a 2013 fatal accident involving an Ayers Corporation S2R Thrush.

The ATSB summary explains that on 18 October 2013, the pilot of an Ayres Corporation S2R Thrush, registered VH-JAY, was conducting aerial agricultural spraying activities on a property near Hyden, Western Australia. At about 1330, following the completion of a number of spray runs and a break for lunch, the pilot departed to complete further spraying. Following the failure of the aircraft to return, a search was initiated. The aircraft wreckage was found a short time later about 1,700 m from the departure airstrip. The aircraft was destroyed and the pilot was fatally injured.

The Coroner adopted the sequence of events as set out in the Australian Transport Safety Bureau (ATSB) final report in relation to the circumstances that led up to the occurrence.

Safety message

Operators and pilots are reminded of the dangers of operating aircraft engines on an unapproved fuel mix as this increases the likelihood of engine damage which could affect the safety of operations. Pilots and operators are also reminded of the need to adhere to an aircraft’s maximum take-off weight to ensure the on-going safety of the aircraft and operations.

Proactive safety action

CASA advised that on 16 May 2014 they wrote to all operators of Thrush aircraft, informing them of exemption CASA EX01/12 – Maximum Take-off Weight – Restricted Category aircraft and aeroplanes engaged in aerial application operations. This letter reminds operators that there is no provision in the exemption to exceed whichever is the highest applicable MTOW specified in:

  1. the aircraft flight manual or approved flight manual supplement;
  2. an approved placard in the aircraft approved by CASA; or
  3. the Type Certificate or Type Certificate Data Sheet for the aircraft.

The letter further advises about weight related airworthiness requirements and time-in-service recording and that the continuing airworthiness instructions for aircraft often include airworthiness limitations that apply to specified components of the aircraft. For safety reasons CASA has mandated compliance with airworthiness limitations via a direction in Civil Aviation Order 100.5. If such requirements apply to an aircraft, then the operator must ensure that the time in service for the aircraft and its components is properly calculated to ensure that airworthiness limitations are not exceeded.

Inquests are separate to ATSB investigations

Coronial investigations are separate to ATSB investigations.

The ATSB's report can be downloaded by clicking on the link: Final report

The Coroner's report can be obtained from the Coroner's Court of WA. Contact details are available at: www.coronerscourt.wa.gov.au Queries regarding the Coroner's findings should be directed to the WA Coroner’s Court

 

 

 

General details
Date: 18 October 2013   Investigation status: Completed  
Time: 1330 WST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): 17 km south east Hyden    
State: Western Australia   Occurrence type: Collision with terrain  
Release date: 16 July 2014   Occurrence class: Operational  
Report status: Final   Occurrence category: Accident  
  Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Ayres Corporation  
Aircraft model S2R  
Aircraft registration VH-JAY  
Serial number 2264R  
Type of operation Aerial Work  
Sector Turboprop  
Damage to aircraft Substantial  
Last update 14 November 2018