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What happened

On 22 March 2014, a Cessna Aircraft Company (Cessna) U206G aircraft, registered VH-FRT, was being used for tandem parachuting operations at Caboolture Airfield, Queensland. At about 1124 Eastern Standard Time, the aircraft took off from runway 06 with the pilot, two parachuting instructors and two tandem parachutists on board. Shortly after take-off, witnesses at the airfield observed the aircraft climb to about 200 ft above ground level before it commenced a roll to the left. The left roll steepened and the aircraft then adopted a nose‑down attitude until impacting the ground in an almost vertical, left-wing low attitude. All of the occupants on board were fatally injured. A post-impact, fuel-fed fire destroyed the aircraft.

What the ATSB found

The ATSB identified that the aircraft aerodynamically stalled at a height from which it was too low to recover control prior to collision with terrain. The reason for the aerodynamic stall was unable to be determined. Extensive fire damage prevented examination and testing of most of the aircraft components. Consequently, a mechanical defect could not be ruled out as a contributor to the accident.

A number of safety issues were also identified by the ATSB. These included findings associated with occupant restraint, modification of parachuting aircraft and the regulatory classification of parachuting operations.

What's been done as a result

The Australian Parachute Federation (APF) mandated a requirement for all member parachute training/tandem organisations to have their own safety management system. The APF have also increased the number of full‑time safety personnel to audit their member organisations.

The Civil Aviation Safety Authority (CASA) has increased the available information on their website about the risks associated with sports aviation. CASA also introduced an Airworthiness Bulletin to provide guidance about co‑pilot side flight control modifications.

In response to the identified safety issues, the ATSB has recommended that CASA take safety action to increase the fitment of the Cessna secondary pilot seat stop modification and reduce the risk associated with the aviation aspect of parachuting operations. Finally, recommendations were issued to CASA and the APF to increase the use of dual‑point restraints in parachuting aircraft.

Safety message

The current classification of parachuting as a private operation means there are fewer risk controls than for other similar aviation activities that also involve payment for carriage. Prospective tandem parachutists should be aware that accident data indicates that parachuting is less safe than other aviation activities, such as scenic flights.

The ATSB’s investigation of this accident, and a previous fatal parachuting accident, indicated that the single-point restraints currently fitted to Australian parachuting aircraft may not be consistently used by occupants. While research shows that they may not be as effective as dual-point restraints at preventing injury in an accident, they do limit the movement of parachutists within the aircraft, therefore reducing the likelihood of load shift during flight. That affords some occupant protection and ensures that the aircraft remains controllable.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Appendices

 

Secondary seat stop modification not mandatory

Despite being categorised as mandatory for the pilot’s seat by the aircraft manufacturer, a secondary seat stop modification designed to prevent uncommanded rearward pilot seat movement and potential loss of control was not fitted to VH-FRT, nor was it required to be under United States or Australian regulations.

Safety Recommendation AO-2014-053-SR-017

The ATSB recommends that the Civil Aviation Safety Authority takes action to strengthen incorporation of Cessna Single Engine Service Bulletin SEB07-5 Secondary seat stop modification.

Dual-point restraints

Research has identified that rear‑facing occupants of parachuting aircraft have a higher chance of survival when secured by dual-point restraints, rather than the standard single-point restraints that were generally fitted to Australian parachuting aircraft.

Safety Recommendation AO-2014-053-SR-018

Safety Recommendation AO-2014-053-SR-019

The ATSB recommends that the Australian Parachute Federation, in conjunction with the Civil Aviation Safety Authority, takes action to increase the usage of dual point restraints in parachuting aircraft that are configured for rear facing occupants.

Classification of parachuting operations

Classification of parachuting operations in the private category did not provide comparable risk controls to other similar aviation activities that involve the carriage of the general public for payment.

Safety Recommendation AO-2014-053-SR-020

The ATSB recommends that the Civil Aviation Safety Authority introduce risk controls to parachuting operations that provide increased assurance of aircraft serviceability, pilot competence and adequate regulatory oversight.

 

 
 

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History of flight

On 22 March 2014, a Cessna Aircraft Company U206G aircraft, registered VH-FRT, was being used for commercial parachuting operations from Caboolture Airfield, Queensland. The aircraft landed at about 1050 Eastern Standard Time,[1] after completing the second flight of the day. Fuel was added to the aircraft from a refuelling facility located at the airfield, which was consistent with the operator’s normal processes.

At approximately 1124, the aircraft took off from runway 06 with the pilot, two parachuting instructors and two tandem parachutists on board. Shortly after take-off, witnesses located at the airfield observed the aircraft climb to about 150 to 200 ft above ground level before it commenced a roll to the left. The left roll steepened and the aircraft adopted a nose-down attitude until it impacted the ground in an almost vertical, left-wing low attitude. A post-impact, fuel-fed-fire destroyed the aircraft. The accident was not survivable.

Figure 1 shows an overview of Caboolture Airfield and the aircraft’s approximate take-off point, flight path and impact point.

Figure 1: Caboolture Airfield overview
Caboolture Airport overviewSource: Google Earth and ATSB

Aircraft details

General information

The Cessna U206G is a high-wing, piston-engine, fixed-undercarriage design. VH-FRT was manufactured in 1977 and first registered in Australia in October 1977 (Figure 2). In 2010 the aircraft was configured for parachuting operations, which meant that all of the seats with the exception of the pilot seat were removed to allow for open floor space for parachuting operations.

The aircraft had a current certificate of airworthiness and certificate of registration. A review of maintenance records indicated that the aircraft was being maintained to a Class B charter standard, as required by the Australian Parachuting Federation. The last recorded maintenance was a 100-hourly inspection, completed on 12 February 2014. At that time the aircraft had completed 11,092.6 airframe hours. The aircraft had a current maintenance release, which was valid until 12 February 2015 or 11,192.6 aircraft hours. 

Figure 2: VH-FRT
Cessna U206 aircraft VH-FRTSource: Burt van Drunick

Pilot information

The pilot held a Commercial Pilot (Aeroplane) Licence that was issued on 24 February 2010. The pilot was appropriately endorsed to fly the Cessna 206, held a Jump Pilot Authorisation and had approximately 1,100 hours of flight experience. The pilot was reported to have been fit and well on the morning of the accident.

Witness information

There were numerous witnesses to the accident located around the airfield and one witness who was piloting an aircraft in the Caboolture Airfield circuit area. Witness accounts varied with respect to the aircraft’s pitch attitude and sounds that the engine and propeller were making at various stages of the flight. However, the statements consistently described the aircraft rolling to the left, which increased in rate as the aircraft turned further left. Some witnesses described this as the aircraft appearing to enter a spiral dive moments before impacting terrain. Others described the final movements of the aircraft as consistent with an aerodynamic stall.[2]

Meteorological information

There was no recorded weather information for the Caboolture Airfield. Witness accounts and images taken soon after the accident indicated that there was 5‑10 kt south-easterly breeze at that time. The witnesses also reported that there was scattered cloud but no rain in the local area at the time of the accident.

Site and wreckage information

The accident site was located in the area between the centre-line of runway 12 and the north-west to south-east perimeter fence at Caboolture Airfield. Ground scarring and impact marks indicated that the left wingtip touched the ground first, then the aircraft cartwheeled before coming to rest about 35 m beyond the initial impact point (Figure 3). The wreckage trail was orientated on a magnetic bearing of about 344°. All extremities of the aircraft were identified in the wreckage, and no parts of the aircraft were identified prior to the start of the wreckage trail. The engine and both wings sustained impact and fire damage. Most of the fuselage was destroyed by the post-impact fire.

A number of aircraft components, including the engine, propeller, flight control components and parts of the pilot’s seat and associated seat rails were recovered for later technical examination.

Video recorders were normally taken on the aircraft as part of the commercial parachuting operation. The recorders were removed from the site for examination, but they were extensively damaged and no information was able to be downloaded.

Figure 3: Main wreckage site
Accident Site of VH-FRTSource: ATSB

Continuing investigation

The investigation is considering a range of scenarios to explain the aircraft’s flight path. These include the possible rearward movement of the pilot’s seat, a load shift, partial power loss and turn back, and a flight control problem. At this stage there is no definitive evidence for any particular scenario.

The investigation is continuing and will include examination of:

  • the engine and propeller
  • various retained aircraft components including flight controls, pilot’s seat and associated structures
  • the aircraft’s maintenance records
  • pilot training records
  • witness statements
  • statements from pilots and passengers of previous flights in the aircraft
  • on-board video recordings from previous flights in the aircraft (downloaded prior to the accident flight)
  • the circumstances of similar Cessna 206 accidents
  • regulations and requirements for parachuting operations.

A final report is expected to be completed within 12 months of the accident. Should any significant safety issues emerge in the course of the investigation, the Australian Transport Safety Bureau will immediately bring those to the attention of the relevant authorities or organisations and publish them if required.

 

 _________

The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.

 



[1]     Eastern Standard Time (EST) is Coordinated Universal Time (UTC) +10 hours.

[2]     Aerodynamic stall is a term used to describe when a wing is no longer producing enough lift to support an aircraft’s weight.

 

 

Safety issues

AO-2014-053-SI-01 - AO-2014-053-SI-02 - AO-2014-053-SI-03 - AO-2014-053-SI-04 - AO-2014-053-SI-05 -  

Secondary seat stop modification not mandatory

Despite being categorised as mandatory for the pilot’s seat by the aircraft manufacturer, a secondary seat stop modification designed to prevent uncommanded rearward pilot seat movement and potential loss of control was not fitted to VH-FRT, nor was it required to be under United States or Australian regulations.

Safety issue details
Issue number:AO-2014-053-SI-01
Who it affects:Single engine Cessna aircraft operators
Status:Safety action pending


 

Unapproved aircraft flight control modifications

Some Cessna 206 parachuting aircraft, including VH-FRT, had their flight control systems modified without an appropriate maintenance procedure or approval. That increased the risk of flight control obstruction.

Safety issue details
Issue number:AO-2014-053-SI-02
Who it affects:Parachute jump operators
Status:Adequately addressed


 

Dual-point restraints

Research has identified that rear‑facing occupants of parachuting aircraft have a higher chance of survival when secured by dual-point restraints, rather than the standard single-point restraints that were generally fitted to Australian parachuting aircraft.

Safety issue details
Issue number:AO-2014-053-SI-03
Who it affects:Australian parachuting industry
Status:Safety action pending


 

Restraint use in parachuting aircraft

It was likely that the parachutists on the accident flight, as well as those that had participated in previous flights, were not secured to the single-point restraints that were fitted to VH-FRT. While research indicates that single-point restraints provide limited protection when compared to dual-point restraints, they do reduce the risk of load shift following an in-flight upset, which can lead to aircraft controllability issues.

Safety issue details
Issue number:AO-2014-053-SI-04
Who it affects:Australian parachuting industry
Status:No longer relevant


 

Classification of parachuting operations

Classification of parachuting operations in the private category did not provide comparable risk controls to other similar aviation activities that involve the carriage of the general public for payment.

Safety issue details
Issue number:AO-2014-053-SI-05
Who it affects:Australian parachuting industry
Status:Safety action pending

 
General details
Date: 22 March 2014 Investigation status: Completed 
Time: 1124 EST Investigation type: Occurrence Investigation 
Location   (show map):Caboolture Airfield Occurrence type:Terrain Collision 
State: Queensland Occurrence class: Operational 
Release date: 23 June 2017 Occurrence category: Accident 
Report status: Final Highest injury level: Fatal 
 
Aircraft details
Aircraft manufacturer: Cessna Aircraft Company 
Aircraft model: U206G 
Aircraft registration: VH-FRT 
Serial number: U20604019 
Type of operation: Private 
Sector: Piston 
Damage to aircraft: Destroyed 
Departure point:Caboolture Airfield, Qld
Destination:Caboolture Airfield, Qld

Explanatory statement

Fatal accident prompts safety recommendations for skydiving operations
 
 
 
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Last update 02 August 2017