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What happened

On 16 December 2013, at about 1215 Eastern Standard Time, a de Havilland DH82A (Tiger Moth) aircraft, registered VH-TSG, took off from the operator’s airstrip at Pimpama, Queensland with a pilot and passenger on board. The purpose of the flight was to conduct a commercial joy flight in the Gold Coast area. At about 1224, 1 minute after the pilot commenced aerobatics, the left wings failed and the aircraft descended steeply; impacting the water about 300 m from the eastern shoreline of South Stradbroke Island. The aircraft was destroyed and the two occupants were fatally injured.

What the ATSB found

The ATSB found that both of the aircraft’s fuselage lateral tie rods, which assist in transferring flight loads through the fuselage, had fractured. The location of the fracture coincided with areas of pre-existing fatigue cracking in the threaded sections of the rods, near the join with the left wing. The tie rods fractured during an aerobatic manoeuvre, resulting in the left lower wing separating from the aircraft and subsequent in-flight break-up. The ATSB also found that the tie rods were aftermarket parts manufactured under an Australian Parts Manufacturer Approval (APMA). In this respect, safety issues were identified in areas of the tie rods’ design and manufacture, as well as in the supporting regulatory approval processes. Safety issues were also identified in the maintenance and operation of the aircraft.

What's been done as a result

The ATSB consulted with the Type Design Organisation, regulators and investigation authorities from Australia, New Zealand and the United Kingdom about the failure of the APMA tie rods, which occurred well before the published retirement life for Tiger Moth tie rods. In response, the United Kingdom Civil Aviation Authority issued an airworthiness directive on 21 March 2014 that mandated the removal from service of all tie rods produced by the same Australian manufacturer. The airworthiness directive was subsequently also mandated by the Australian Civil Aviation Safety Authority and the New Zealand Civil Aviation Authority. Significant additional safety action is proposed by the Type Design Organisation to further enhance the safety of all Tiger Moth operations. In addition, the ATSB has issued a safety recommendation to the Civil Aviation Safety Authority to take action to provide assurance that over 1,000 other parts approved for APMA at about the same time as the tie rods were appropriately considered before approval.

Safety message

This accident emphasises the need for the full consideration of a part’s service history when redesigning and manufacturing parts critical to the structural integrity of the aircraft. It also shows the important role of the regulator in ensuring that parts approved under an APMA have been fully considered and shown to comply with the design requirements. Further, in the context of maintenance, it shows the importance of utilising genuine or approved substitute aircraft parts that are suitable for purpose, especially in sections of the aircraft that are critical to flight.

In addition, the ATSB cautions commercial vintage aircraft operators about the risks associated with aircraft age and the importance of understanding the originally-intended use of the design before commencing their operations.

 Tiger Moth aircraft VH-TSG

VH-TSG

Source: David Welch, Air-Britain Photographic Images Collection

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Appendices

 
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Preliminary reoport released on 24 February 2015

On 16 December 2013, at approximately 1215 Eastern Standard Time, a de Havilland DH82A (Tiger Moth) aircraft, registered VH-TSG, took off from the operator’s airstrip at Pimpama, Queensland with a pilot and passenger on board. The purpose of the flight was to conduct a commercial joy flight in the Gold Coast area. At about 1224, 1 minute after the pilot commenced aerobatics, the left wings failed and the aircraft descended steeply; impacting the water about 300m from the eastern shoreline of South Stradbroke island. The aircraft was destroyed and the two occupants were fatally injured.

Preliminary examination indicated that both of the aircraft’s fuselage lateral tie rods, which join the lower wings to the fuselage, had fractured at areas of significant, pre-existing fatigue cracking in the threaded section near the join with the left wing. These tie rods, part number JRA-776-1, were manufactured under an Australian Parts Manufacturing Approval.

The ATSB has not, at this preliminary stage of its investigation, determined whether the failure of the fuselage lateral tie rods, or another mode of wing structural failure, was the initiator of the left wing separations. However, this Preliminary Report includes a safety issue that advises of the JRA-776-1 tie rod fatigue cracking and includes a Safety Advisory Notice to Tiger Moth operators about this safety issue.

 

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Civil Aviation Safety Authority Australian Parts Manufacturer Approval implementation approvals

Safety Issue

Over 1,000 parts were approved by the Civil Aviation Safety Authority for Australian Parts Manufacturer Approval using a policy that accepted existing design approvals without the authority confirming that important service factors, such as service history and life‑limits, were appropriately considered.

Safety Recommendation AO-2013-226-SR-044

The ATSB recommends that the Civil Aviation Safety Authority takes action to provide assurance that all of the replacement parts that were approved for Australian Parts Manufacturer Approval by the Regulatory Reform Program Implementation team in 2003 have appropriately considered important service factors, such as service history and life‑limits.

 

Safety issues

AO-2013-226-SI-01 - AO-2013-226-SI-04 - AO-2013-226-SI-06 - AO-2013-226-SI-05 - AO-2013-226-SI-02 - AO-2013-226-SI-03 - AO-2013-226-SI-07 - AO-2013-226-SI-08 -  

Fuselage lateral tie rod fatigue cracks

The two JRA-776-1 fuselage lateral tie rods fitted to de Havilland DH82A Tiger Moth, registered VH-TSG, had significant, pre-existing fatigue cracks in the threaded sections. The parts’ service life was significantly less than the published retirement life for DH82A tie rods of 2,000 flight hours or 18 years).

Safety issue details
Issue number:AO-2013-226-SI-01
Who it affects:Owners and operators of DH82 and DH82A Tiger Moth aircraft fitted with JRA 776 1 fuselage lateral tie rods
Status:Adequately addressed


 

Unknown fatigue life of alternative tie rod design

When approving the change in material for the manufacture of the replacement tie rods, the design engineer did not identify that the original parts had a life limitation, or that they had shown susceptibility to fatigue cracking. As a result, the engineer did not compare the fatigue performance of the alternative design to the original, and the replacement tie rods were manufactured to that design and released into service with an unknown fatigue life.

Safety issue details
Issue number:AO-2013-226-SI-04
Who it affects:Owners and operators of DH82 and DH82A Tiger Moth aircraft fitted with JRA 776 1 fuselage lateral tie rods
Status:Adequately addressed


 

Fuselage lateral tie rod Australian Parts Manufacturer Approval

It was likely that, because of the Civil Aviation Safety Authority’s policy at the time, their engineering assessment of the tie rod design for inclusion in the manufacturer’s Australian Parts Manufacturer Approval did not consider the service history of the original tie rods or identify that they were subject to airworthiness directive AD/DH 82/10. Consequently, the assessment team was likely unaware that the original tie rods were subject to a life limitation, and did not require the life limits for the replacement tie rods to be established.

Safety issue details
Issue number:AO-2013-226-SI-06
Who it affects:Owners and operators of DH82 and DH82A Tiger Moth aircraft fitted with JRA 776 1 fuselage lateral tie rods
Status:Adequately addressed


 

Australian Parts Manufacturer Approval tie rods not identified by part and serial number

The JRA-776-1 fuselage lateral tie rods that were inspected by the ATSB were not appropriately marked with part and serial numbers, affecting the traceability and service history of the parts in a number of aircraft. 

Safety issue details
Issue number:AO-2013-226-SI-05
Who it affects:Owners and operators of DH82 and DH82A Tiger Moth aircraft fitted with JRA 776 1 fuselage lateral tie rods
Status:Adequately addressed


 

Australian Parts Manufacturer Approval manufacturer’s quality system

The manufacturer’s quality system did not prevent non-conforming tie rods from being released for use on aircraft. 

Safety issue details
Issue number:AO-2013-226-SI-02
Who it affects:Owners and operators of DH82 and DH82A Tiger Moth aircraft fitted with JRA 776 1 fuselage lateral tie rods
Status:Adequately addressed


 

Non-standard Joint H fitting upper attachment hardware

Together with a number of other Australian Tiger Moths, VH-TSG was fitted with non‑standard Joint H attachment bolts that did not conform to the original design with the result that the integrity of the Joint H could not be assured.

Safety issue details
Issue number:AO-2013-226-SI-03
Who it affects:Owners and operators of DH82 and DH82A Tiger Moth aircraft
Status:Safety action pending


 

Civil Aviation Safety Authority Australian Parts Manufacturer Approval implementation approvals

Over 1,000 parts were approved by the Civil Aviation Safety Authority for Australian Parts Manufacturer Approval using a policy that accepted existing design approvals without the authority confirming that important service factors, such as service history and life‑limits, were appropriately considered.

Safety issue details
Issue number:AO-2013-226-SI-07
Who it affects:Operators of aircraft fitted with parts manufactured under those Australian Parts Manufacturer Approvals
Status:Safety action pending


 

Commercial Tiger Moth joy flight operations with high aerobatic utilisation

Although a number of aerobatic manoeuvres were permitted in Tiger Moth aircraft, there was no limitation on the amount of aerobatic operations that was considered to be safe. As a result, operators may be unaware that a high aerobatic usage may exceed the original design assumptions for the aircraft. 

Safety issue details
Issue number:AO-2013-226-SI-08
Who it affects:Commercial Tiger Moth joy flight operators
Status:Safety action pending

 
General details
Date: 16 Dec 2013 Investigation status: Completed 
Time: 1224 EST Investigation type: Occurrence Investigation 
Location   (show map):300 m east of South Stradbroke Island Occurrence type:In-flight break-up 
State: Queensland Occurrence class: Operational 
Release date: 21 Jan 2016 Occurrence category: Accident 
Report status: Final Highest injury level: Fatal 
 
Aircraft details
Aircraft manufacturer: de Havilland Aircraft Pty Ltd 
Aircraft model: DH-82A Tiger Moth 
Aircraft registration: VH-TSG 
Serial number: DHC78 
Type of operation: Charter 
Sector: Piston 
Damage to aircraft: Destroyed 
Departure point:Private airstrip, Qld
Destination:Private airstrip, Qld
 
 
 
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Last update 24 February 2016