Aviation safety investigations & reports

Loss of control and collision with terrain involving Cessna T310R, VH-JMW, 40 km SSW of Port Macquarie, NSW, on 28 October 2017

Investigation number:
AO-2017-105
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

During the afternoon of 28 October 2017, a Cessna Aircraft Company T310R, registered VH-JMW (JMW) was conducting a return flight from The Lakes airstrip, New South Wales to Toowoomba Airport, Queensland with the pilot and one passenger on board.

On the return flight from Toowoomba, during descent to The Lakes, and while about 8 km from the runway, a witness recalled hearing the sound of what he thought was a single-engine aircraft ‘cough’ and then stop. Shortly afterwards, JMW was seen descending slowly with the landing gear extended. The aircraft then ‘jerked’ suddenly, rolled to the left and descended rapidly to the ground.

The pilot and passenger were fatally injured and the aircraft was destroyed.

What the ATSB found

The ATSB identified that during the final descent towards The Lakes airstrip runway, the left engine was not producing power and the right engine was operating at low or intermittent power.

Following the loss of engine power a safe flying speed was not maintained resulting in a loss of control and collision with terrain due to either an aerodynamic stall, asymmetric power effects or a combination of both.

The loss of engine power was probably the result of either insufficient fuel for the flight or an in‑flight fuel management error.

Safety message

A loss of power in an aeroplane requires different responses depending on whether the aircraft has single or multiple engines. However, regardless of the configuration, in order to maximise the survivability outcome it is imperative that the pilot retains control of the aircraft and maintains a safe airspeed. Where the aircraft’s performance degrades to the point that continued safe flight is not possible, the pilot must shift focus to conducting a forced landing.

Pilots also need to routinely exercise good fuel-management practices in order to maintain the highest level of safety and avoid fuel exhaustion or starvation events. Civil Aviation Advisory Publication 234-1(2) provides guidance on the current fuel requirements and good fuel-management practices.

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The occurrence

Context

Safety analysis

Findings

Sources and submissions

Preliminary report

Preliminary report

Published: 8 December 2017

On 28 October 2017, a Cessna Aircraft Company T310R, registered VH-JMW, was being operated on a private flight from Toowoomba, Queensland to The Lakes aerodrome, New South Wales. The aircraft had been flown from The Lakes to Toowoomba earlier that day. The aircraft departed Toowoomba at 1434 Eastern Daylight-saving Time (EDT)[1]. The pilot was the owner of the aircraft and there was a passenger in the other front seat.

During the flight, transponders in the aircraft provided flight information indicating that the aircraft flew at 9,500 ft in the cruise. Weather forecasts and observations indicated good weather conditions throughout the flight, with a light easterly wind in the vicinity of the destination.

About half a nautical mile north of The Lakes aerodrome, witnesses driving south on the Pacific Highway observed the aircraft flying just to the west of the highway at low altitude in a southerly direction. The landing gear was extended and the aircraft was descending slowly. The aircraft was then observed to roll left and descend rapidly.

The aircraft collided with terrain at approximately 1555, in a narrow wooded strip of land east of the Pacific Highway, between the highway and the main northern railway line. The accident was 800 m from The Lakes runway 16 threshold, in line with the runway direction (Figure 1). The pilot and passenger were fatally injured.

Figure 1: Flight path approaching The Lakes. Radar data was lost below 900 ft altitude

Figure 1: Flight path approaching The Lakes. Radar data was lost below 900 ft altitude.

Source: Google Earth modified by ATSB

Aircraft information

VH-JMW was a Cessna T310R, six seat, twin-engine aircraft, powered by two Teledyne Continental Motors TSIO-520-NB turbocharged engines (Figure 2). It had six fuel tanks, comprising the main fuel tanks in the wingtip pods, and two auxiliary fuel tanks in each wing.

Figure 2: Cessna T310R VH-JMW

Figure 3: Cessna T310R VH-JMW

Source: flightaware.com

Wreckage examination

On-site examination of the wreckage, surrounding markings on trees and the ground indicated that the aircraft impacted terrain in a steep nose-down attitude and banked to the left. The aircraft was in a landing configuration.

The left wing had separated outboard of the left engine, and both the wing-tip pods had separated from the wings. The remaining fuel tanks were also breached and no fuel was found, however a smell of aviation fuel was noted by emergency responders at the accident site. There was no evidence of fire.

Examination of the engines and propellers indicated that the left engine was producing no power and the right engine was likely producing low power at the time of the accident.

A number of aircraft components, instruments and electronic devices were recovered from the accident site by the ATSB for further examination.

The aircraft was not equipped with a flight data recorder or a cockpit voice recorder, nor was it required to be.

Ongoing investigation

The investigation is continuing and will include consideration of the:

  • pilot’s qualifications, experience and medical information
  • fuel planning for the flight
  • component examination
  • witness information
  • weather information
  • recovered instruments and available electronic data.

 

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The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this report. As such, no analysis or findings are included in this update.

 

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  1. Eastern Daylight-saving Time (EDT): Coordinated Universal Time (UTC) + 11 hours. The local departure time was Eastern Standard Time (EST): UTC + 10 hours, however the destination time zone is used throughout this report.
General details
Date: 28 October 2017   Investigation status: Completed  
Time: 1555 EDT   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): 40 km SSW Port Macquarie (Johns River)   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Loss of control  
Release date: 29 January 2020   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model T310R  
Aircraft registration VH-JMW  
Serial number 310R1802  
Operator Private  
Type of operation Private  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Toowoomba, Queensland  
Destination The Lakes, (Johns River) New South Wales  
Last update 29 January 2020