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What happened

On 6 November 2015, at about 1829 Eastern Daylight Saving Time, the pilot of a Cessna Aircraft Company 310R registered VH‑BWZ, on a private flight from Moorabbin to Mildura, Victoria lost control of the aircraft near Mildura Airport and collided with terrain. The pilot was fatally injured and the aircraft destroyed.

What the ATSB found

Witnesses reported that when on final approach to land at Mildura, at low altitude, the aircraft yawed to the left, dropped its left wing and rapidly lost altitude. A number of factors contributed to the loss of control. The aircraft’s left engine was found to have been starved of fuel and at the time of the accident was not producing power. The left propeller was found to be towards fine pitch, not feathered (rotation of propeller blades to an edge-on angle to the airflow to minimise aircraft drag following an in-flight engine failure or shutdown), and the flaps and landing gear were fully extended, consistent with a normal landing configuration. In that configuration with the engine not producing power, the aircraft’s performance would have degraded to the extent that altitude could not be maintained.

The ATSB was unable to ascertain why the left engine was starved of fuel, nor could it be determined when the engine was starved of fuel. The ATSB did establish that it was likely the aircraft was carrying a substantial amount of fuel on board for continued flight and that the left engine and left propeller were capable of normal operation.

Several components recovered from the aircraft were tested. Some abnormalities were identified, however, it was unlikely that these contributed to the accident. No mechanical defects were identified that may have contributed to the accident. However, examination of the aircraft was limited due to the extent of the damage resulting from the post-impact fire.

It was likely that the combination of the inoperative left engine with the propeller in the fine pitch and the right engine at high power resulted in asymmetric thrust. Whilst at low altitude in a landing configuration with asymmetric thrust, the pilot lost control of the aircraft.

Safety message

In situations such as an inoperative engine condition, the aircraft’s landing gear, flaps and or propeller management can potentially impose increased drag impacting significantly on the aircraft’s performance. Low airspeed in critical phases of flight such as take-off and landing can further exacerbate the situation. Pilots need to train, maintain their skills and constantly monitor aircraft systems to be prepared for abnormal flight situations, especially during critical phases of flight where greater attentional focus is required.

While ATSB research has found that the rate of power loss accidents in multi-engine aircraft occur less than that in single-engine aircraft, they are more likely to be fatal and overwhelmingly due to the potential for loss of control. In particular, the approach phase of flight is considered riskier due to lower altitudes and lower available aircraft energy.

This accident has emphasised the adverse consequences of aircraft configuration on performance with one-engine inoperative, particularly when at low altitudes. It reinforced the importance of pilots remaining well versed in engine failure response procedures and being aware of the drag penalties associated with varying configurations. It also highlighted the challenges associated with recognising an asymmetric condition when in a descent or at a low power setting. When faced with an inoperative engine in a multi-engine aircraft, attention to both aircraft control and performance is crucial for safe flight.

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The occurrence

Safety analysis

Findings

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General details
Date: 06 November 2015 Investigation status: Completed 
Time: 1830 ESuT Investigation type: Occurrence Investigation 
Location   (show map):Mildura Airport Occurrence type:Collision with terrain 
State: Victoria Occurrence class: Operational 
Release date: 30 October 2017 Occurrence category: Accident 
Report status: Final Highest injury level: Fatal 
 
Aircraft details
Aircraft manufacturer: Cessna Aircraft Company 
Aircraft model: 310R 
Aircraft registration: VH-BWZ 
Serial number: 310R1611 
Type of operation: General Aviation 
Sector: Piston 
Damage to aircraft: Destroyed 
Departure point:Moorabbin, Vic.
Destination:Mildura, Vic.
 
 
 
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Last update 30 October 2017