Aviation safety investigations & reports

Runway excursion involving a Cessna 550, VH-FGK, at Lismore Airport, NSW, on 25 September 2015

Investigation number:
Status: Completed
Investigation completed

Final Report

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What happened

On 25 September 2015, a Cessna 550 aircraft (Citation Bravo), registered VH-FGK, taxied at Lismore Airport for a private flight to Baryulgil, New South Wales. The flight crew consisted of a captain and copilot, who were the only occupants of the aircraft.

The flight crew did not detect anything abnormal during the taxi and take-off roll, until the captain attempted to rotate the aircraft to the take-off pitch attitude. When the aircraft had achieved the required rotate speed, the captain applied the normal backpressure on the control column to achieve a standard rate of rotation, and the aircraft did not rotate. The captain then applied full backpressure and reported that the controls felt very heavy. Neither the captain nor the copilot detected any change in the aircraft’s pitch attitude or any indication of pitch-up on the attitude direction indicator.

The captain rejected the take-off, applied full braking and reverse thrust, but the aircraft overran the runway. The nose landing gear detached from the aircraft about 50 m beyond the end of the sealed runway, and the aircraft came to rest in long grass and mud. The aircraft sustained substantial damage, and the captain and copilot were uninjured.

What the ATSB found

The aircraft did not accelerate normally as the acceleration was retarded by drag associated with rolling friction. This was indicative of partial brake pressure remaining during the take-off run. The partial brake pressure was possibly due to the parking brake being selected on at the holding point with enough pressure to retard aircraft acceleration during the take-off, but not sufficient to prevent the aircraft reaching rotate speed.

Furthermore, the nose-down moment generated by the partial brake pressure probably prevented the aircraft rotating sufficiently to become airborne, despite normal nose-up elevator deflection.

Heat in the brakes due to partial pressure during the take-off run may have reduced their effectiveness when the captain rejected the take-off, contributing to the runway overrun.

What has been done as a result

The Australian Transport Safety Bureau issued a safety recommendation that Textron Aviation (Cessna) take safety action to address the fact that Citation aircraft do not have an annunciator light to show that the parking brake is engaged and the Cessna 'before take-off' checklist does not include a check to ensure the parking brake is disengaged.

Safety message

For pilots, this incident highlights the importance of attention to the configuration of the aircraft and cockpit settings at all stages of flight, but particularly during take-off. For manufacturers, this incident highlights the importance of systems that bring an irregular or abnormal configuration or cockpit setting to the attention of the crew, especially when that configuration has the potential to adversely affect aircraft performance or control.

Accident site of Cessna 550 aircraft (Citation Bravo), registered VH-FGK, at Lismore Airport

Accident site. Source: Aircraft owner
Source: Aircraft operator

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[Download  PDF: 2.15MB]
Alternate: [Download  DOCX: 6.7MB]

The occurrence


Safety analysis


Safety issues and actions

Sources and submissions


Safety Issue

Go to AO-2015-114-SI-01 -

No cockpit annunciation or checklist item for parking brake status

The Citation aircraft did not have an annunciator light to show that the parking brake is engaged, and the manufacturer’s before take-off checklist did not include a check to ensure the parking brake is disengaged.

Safety issue details
Issue number: AO-2015-114-SI-01
Who it affects: All owners and operators of Cessna Citation aircraft
Status: Safety action pending
General details
Date: 25 September 2015   Investigation status: Completed  
Time: 13:00 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Lismore Airport    
State: New South Wales   Occurrence type: Control - Other  
Release date: 25 July 2016   Occurrence category: Accident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 550  
Aircraft registration VH-FGK  
Serial number 550-0852  
Type of operation Private  
Sector Jet  
Damage to aircraft Substantial  
Departure point Lismore, NSW  
Destination Baryulgil, NSW  
Last update 14 November 2018