Updated: 7 June 2019
The investigation into the collision with terrain involving Cessna 172S, VH-EWE, near Moorabbin Airport, Victoria, on 8 June 2018 is continuing.
The investigation is currently in the examination and analysis phase, which includes the examination of retained aircraft and engine components, maintenance documentation, the pilot’s experience, fuel records, and available electronic data.
During this phase, the available evidence is reviewed and evaluated to determine its relevance, validity, credibility, and relationship to other evidence and to the occurrence. Evidence can be vague, incomplete and or contradictory. This may prompt the collection of more evidence, which in turn needs to be analysed and examined – potentially adding to the length of an investigation.
Once the evidence analysis phase is complete, a final report will be drafted and undergo a rigorous internal review to ensure the report findings adequately and accurately reflect the analysis of available evidence. Final investigation reports also undergo other technical and administrative reviews to ensure they meet national and international standards for transport safety investigations.
Following the completion of the internal review, a draft of the final report will be sent to all directly involved parties for their comment before the report is finalised and published
Currently, the anticipated completion and publication date of the final report is during the fourth quarter of 2019. However, should any safety issues be identified during any phase of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.
Preliminary report published: 18 July 2018
On 8 June 2018, a Cessna Aircraft Company C172S, registered VH-EWE (EWE), was being operated on a private flight from, and intending to return to, Moorabbin Airport, Victoria. The flight was the first one after scheduled maintenance. The pilot, an employee of the maintenance organisation, was the sole occupant.
The aircraft departed Moorabbin Airport at about 1600 Eastern Standard Time. Recorded Air Traffic Control (ATC) data showed that the aircraft climbed to an altitude of 3,000 ft above mean sea level and tracked towards Tyabb, Victoria.
At 1707, the pilot reported to Moorabbin ATC that EWE was at reporting point GMH at 1,500 ft, inbound to Moorabbin. ATC instructed the pilot to join base for runway 35 Right (R). At 1710, ATC requested EWE change runways to 35 Left (L), due to the number of aircraft tracking for 35R. The pilot accepted the runway change and at 1712, EWE was cleared to land on runway 35L. At 1713, the pilot of EWE broadcast a MAYDAY radio call and stated “we’ve got engine failure”. Shortly after, the aircraft was observed in a descending left turn.
The aircraft initially contacted a power line and fence before coming to rest on a residential street against a parked car (Figure 1). The pilot was fatally injured and a post-impact fuel-fed fire destroyed the aircraft. There was also damage to a residential property and the parked car.
The Cessna 172S aircraft was manufactured in 2006. It had 6,348 hours in service prior to the accident flight and was predominantly used for flight training. The aircraft was fitted with a Lycoming IO-360-L2A fuel injected engine and McCauley two-blade, fixed pitch propeller.
The maintenance carried out on EWE before the accident flight included a periodic inspection and scheduled engine change. A valid maintenance release had been issued just prior to the accident flight.
The installed engine had recently undergone a scheduled inspection and overhaul at another maintenance facility. As part of that process, the engine had been run on a test bed at the overhaul facility for about 2 hours. Post installation into EWE, it was reported that the engine was twice operated on the ground for a total of about 30 minutes.
On-site examination of the wreckage and surrounding ground markings indicated that the aircraft collided with terrain in a nose‑down attitude. The tail of the aircraft twisted clockwise as a result of the impact with the fence and was inverted. Evidence of the fire extended down the street, and was indicative of fuel being released with the rupturing of the fuel tanks.
The degree of propeller damage observed on-site was consistent with the engine not producing power at the time of impact. The engine, propeller and several other components were retained for further examination.
The aircraft was not equipped with a flight data recorder or cockpit voice recorder, nor was it required to be.
Engine and propeller examination
The engine and propeller were subsequently examined at an independent engine overhaul facility, under ATSB supervision. Representatives from the Civil Aviation Safety Authority, the aircraft maintenance organisation, the engine overhaul facility, and the aircraft insurer were present at the engine disassembly.
This examination did not identify evidence of a mechanical failure of the engine. Some additional components, including those associated with the fuel system, were retained for further examination.
The investigation is continuing and will include consideration of the:
- examination of retained aircraft and engine components
- maintenance documentation
- pilot’s experience
- aircraft fuel records
- audio analysis of engine sound (from ATC radio recordings)
- available electronic data.
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 preliminary report. As such, no analysis or findings are included in this report.
The ATSB is investigating the collision with terrain of a Cessna 172, VH-EWE, that occurred near Moorabbin Airport, Victoria on 8 June 2018.
During final approach, the aircraft collided with terrain. The aircraft was destroyed and the pilot, who was the sole occupant, was fatally injured.
As part of the investigation, the ATSB will be examining the site, retaining several components from the wreckage for further examination, interviewing witnesses and gathering additional information.
A final report will be released at the end of the investigation.
Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.
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|Date:||08 June 2018||Investigation status:||Active|
|Time:||1713 EST||Investigation level:||Defined - click for an explanation of investigation levels|
|Location:||near Moorabbin Airport||Investigation phase:||Examination and analysis|
|State:||Victoria||Occurrence type:||Collision with terrain|
|Release date:||07 June 2019||Occurrence category:||Accident|
|Report status:||Preliminary||Highest injury level:||Fatal|
|Anticipated completion:||4th Quarter 2019|
|Aircraft manufacturer||Cessna Aircraft Company|
|Operator||Oxford Aviation Academy (Aust.)|
|Type of operation||Aerial Work|
|Damage to aircraft||Destroyed|
|Departure point||Moorabbin, Vic.|