Aviation safety investigations & reports

Collision with terrain involving Diamond DA40, VH-MPM, 42 km west of Southport Aerodrome, Queensland, on 26 September 2017

Investigation number:
AO-2017-096
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 26 September 2017, an instructor and student conducted a training flight in a Diamond Aircraft Industries DA40 aircraft, registered VH-MPM, from Archerfield Airport, Queensland. The flight training organisation was Aircrew Training and Support Pty Ltd, and the purpose of the flight was a simulated Recreational Pilot Licence (RPL) flight test to prepare the student for an upcoming RPL flight test.

The aircraft entered a developed spin during manoeuvres consistent with advanced stall recovery training which likely included intentional incipient spins. The spin continued until the aircraft collided with terrain. The instructor and student were fatally injured and the aircraft was destroyed.

What the ATSB found

The ATSB found that the aircraft limitation prohibiting intentional spins was intended to include incipient spins. However, the manoeuvre was not defined and some operators considered that the manoeuvre was not an intentional spin. In addition, the aircraft was not certified for developed spin recovery, and the capability of the aircraft to recover from a developed spin had not been established nor was it required to be.

The ATSB also found that the instructor could not or did not prevent the aircraft from entering a developed spin, for reasons that could not be established.

The instructor’s flight records showed no evidence of spin training since his initial instructor training in January 2011. After this initial training, there was no requirement for an instructor to undergo any further spin training. However, a week before the accident flight, the student had mishandled the recovery from an incipient spin and the accident flight instructor had taken control of the aircraft and recovered, showing that he had the ability to recover from a spin at that stage of development.

What’s been done

The ATSB has issued a Safety Advisory Notice (AO‑2017‑096‑SAN-012) for training organisations conducting incipient spins in non-spin-permitted aircraft.

The Civil Aviation Safety Authority will review incipient spin recovery guidance provided in the Flight Instructor Manual.

Safety message

Although the reasons for the accident could not be fully established, the investigation identified varying interpretations of an ‘incipient spin’. Operators and pilots should clarify with manufacturers the extent to which the early stages of a spin are permissible and ensure that aircraft are always operated in accordance with limitations.

Furthermore, operators should have procedures, and instructors should take all steps, to ensure that they maintain the necessary skills to avoid unintentional spins and recover from both incipient and developed spins.

The New Zealand Civil Aviation Authority booklet, Spin Avoidance and Recovery provides valuable guidance for pilots in spin avoidance and recovery. The booklet provides the following advice for pilots regarding spin recovery:

To have a chance at recovery, the pilot must immediately recognise the spin, and its direction, know exactly what to do in the right order, and then execute the procedure correctly the first time.

VH-MPM accident site

VH-MPM accident site. Source: ATSB

Source: ATSB

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The occurrence

Context

Safety analysis

Findings

Safety action

General details

Sources and submissions

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General details
Date: 26 September 2017   Investigation status: Completed  
Time: 0943 AEST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): 42 km W of Southport Aerodrome   Investigation phase: Final report: Dissemination  
State: Queensland   Occurrence type: Collision with terrain  
Release date: 22 May 2019   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Diamond Aircraft Industries  
Aircraft model DA40-180  
Aircraft registration VH-MPM  
Serial number 40.674  
Operator Aircrew Training and Support Pty Ltd  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Archerfield Airport, Qld  
Destination Archerfield Airport, Qld  
Last update 22 May 2019