Aviation safety investigations & reports

Collision with terrain involving Van’s RV-6A, VH-JON, 8 km south of Moorabbin Airport, Victoria, on 14 October 2014

Investigation number:
AO-2014-164
Status: Completed
Investigation completed

Final Report

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What happened

On the afternoon of 14 October 2014, the pilot/owner of an amateur-built Van’s Aircraft Inc. RV-6A aircraft, registered VH-JON and operated in the ‘experimental’ category, departed Moorabbin Airport, Victoria on a local flight.

Shortly after reaching a cruise altitude of 2,900 ft, the aircraft descended to 2,500 ft. After that time, no further air traffic control radar returns were received from the aircraft. The aircraft descended rapidly and a witness reported observing objects falling from the aircraft. The aircraft subsequently collided with the ground next to a house in the suburb of Chelsea, 8 km south of Moorabbin. The pilot was fatally injured and the aircraft was destroyed.

Following the accident, members of the public found a number of aviation-related items away from the accident site that belonged to the pilot.

What the ATSB found

The liberation of the items from the aircraft’s interior indicated that the canopy likely opened in‑flight. However, this was based on the assumption that the items were initially inside the cabin.

Examination of the primary and secondary canopy locks found varying degrees of damage and one component was missing. Therefore, the state of the locking mechanisms prior to the impact could not be established.

It was possible that the pilot was startled and distracted after the canopy opened due to the severe cockpit wind, noise and debris flying about. Though, the extent to which this contributed to the occurrence was unknown.

Also, while the ATSB was unable to determine how the canopy opening would have affected aircraft control, there were indications that the pilot was attempting to respond to the situation. However, for reasons undetermined, recovery did not occur.

Finally, the ATSB identified a safety issue regarding the potential for the in‑flight opening of a tip‑up, forward-hinged canopy to result in a significant pitch down tendency in a number of Van’s Aircraft Inc. models that may affect aircraft control.

What’s been done as a result

Van’s Aircraft Inc. developed a service letter for distribution to builders and operators highlighting the varying consequences of a canopy opening in-flight, in particular, involving a tip-up canopy. The letter recommends inspecting the canopy locking mechanism to confirm that it operates as designed and to ensure the mechanism fully engages when closed, and highlights the need to secure the secondary latch at the top-rear of the canopy in the RV-6/7/9 design prior to take-off.

Additionally, the ATSB has issued a safety advisory notice to all owners of Van’s aircraft to highlight the findings of this investigation.

Safety message

This accident and other reported experiences highlight the varying consequences when a canopy opens in-flight from no effect to a sudden pitch down. The result can vary from being relatively benign to significant, but pilots could expect an element of startle and distraction. Additionally, the ATSB reminds pilots to check the security of the canopy prior to take-off.

Amateur-built Van’s Aircraft RV-6A aircraft, registered VH-JON
Amateur-built Van’s Aircraft Inc. RV-6A aircraft, registered VH‑JON
Source: Supplied

 

Download Final Report
[Download  PDF: 1.92MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Safety Advisory Notice

Detecting an unsecured canopy prior to take-off could prevent in-flight control issues resulting in injury or aircraft damage.

AO-2014-164-SAN-012: Is your canopy secured?

Photos

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Safety Issue

Go to AO-2014-164-SI-01 -

Potential adverse effects of a tip-up canopy opening in-flight

In‑flight opening of the tip-up canopy in a number of Van’s Aircraft Inc. models has resulted in varying consequences, including a significant pitch down tendency, increasing the risk of a loss of control. 

Safety issue details
Issue number: AO-2014-164-SI-01
Who it affects: Owners of Van’s aircraft fitted with a tip-up canopy
Status: Adequately addressed
General details
Date: 14 October 2014   Investigation status: Completed  
Time: 1326 EDT    
Location   (show map): 8 km south of Moorabbin    
State: Victoria   Occurrence type: Collision with terrain  
Release date: 25 November 2016   Occurrence class: Operational  
Report status: Final   Occurrence category: Accident  
  Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Amateur Built Aircraft  
Aircraft model Van’s RV-6A  
Aircraft registration VH-JON  
Type of operation Private  
Sector Piston  
Damage to aircraft Destroyed  
Last update 18 April 2017