Aviation safety investigations & reports

Collision with terrain involving Jabiru J170, 24-5215, at Yarram aerodrome, Victoria on 7 September 2016

Investigation number:
AO-2016-112
Status: Completed
Investigation completed

Final Report

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What happened

On 7 September 2016, the pilot of a Jabiru J170-C aircraft, registered 24-5215, approached to land, or perform a ‘touch-and-go’ manoeuvre, on runway 09 at Yarram aerodrome, Victoria, as part of a solo training flight. The pilot mishandled the landing attempt and lifted off to perform a go-around. The aircraft was observed at 50 to 100 ft above the aerodrome in a left wing down 30° angle of bank prior to it entering a steep descent consistent with an aerodynamic stall. The aircraft collided with the terrain and the pilot was fatally injured.

What the ATSB found

The ATSB found that the aircraft was likely subject to mechanical turbulence at the threshold of runway 09 at Yarram aerodrome. Trees and hangars on the north-eastern perimeter of the aerodrome were known locally to cause turbulence in the last 50 ft of the approach when the wind gusted out of the east-northeast. This information was not published in the Airservices Australia En Route Supplement Australia entry for Yarram aerodrome. The pilot was also likely affected by physical and mental fatigue given their age, medical history and recent physical labour. Fatigue’s effect on attention, reaction time, and vigilance likely exacerbated the pilot’s mishandling of the landing attempt and the subsequent go-around.

Safety message

Pilots and flying school operators should ensure they have thorough knowledge of the effects of weather on the pilot’s destinations and plan accordingly prior to flight. They should also remain cognisant of the effects of fatigue on the individual at different stages of their life. All pilots need to take into account how lifestyle changes, age, medical history, and medication may affect their fatigue.

Download Final Report
[Download  PDF: 1.39MB]
 
 
 

The occurrence

Safety analysis

Findings

Safety issues and actions

Sources and submissions

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General details
Date: 07 September 2016   Investigation status: Completed  
Time: 15:44 EST    
Location   (show map): Yarram Airfield   Investigation type: Occurrence Investigation  
State: Victoria   Occurrence type: Collision with terrain  
Release date: 31 July 2017   Occurrence class: Operational  
Report status: Final   Occurrence category: Accident  
  Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Jabiru Aircraft Pty Ltd  
Aircraft model J170-C LSA  
Aircraft registration 24-5215  
Serial number 177  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Substantial  
Departure point Yarram, Vic.  
Destination Yarram, Vic.  
Last update 14 November 2018