Aviation safety investigations & reports

Loss of power on take-off and forced landing involving Cessna 182, VH-DGF, Tooradin, Victoria on 6 January 2019

Investigation number:
AO-2019-002
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On the morning of 6 January 2019, a Cessna 182G, registered VH-DGF, took off from Tooradin Airfield to conduct parachuting operations. The pilot reported that soon after take-off, at about 400 ft above the ground, the engine sustained a sudden power loss. After being unable to resolve the problem, the pilot conducted a forced landing in a nearby paddock.

During the forced landing, the aircraft collided with trees and a fence, which resulted in substantial damage. There were no injuries.

What the ATSB found

The ATSB found that the carburettor contained aluminium oxide corrosion deposits which, when loosened, likely blocked fuel flow within the carburettor, resulting in the aircraft engine losing power. Periodic inspections (every 100 hours or 12 months) play a vital role in ensuring the serviceability of an aircraft’s engine, and these inspections had a requirement to drain and flush the carburettor. However, the extent to which this action was actually conducted during the six inspections since the engine and carburettor were overhauled could not be determined.

The engine had periods of inactivity over the preceding years, and maintenance on the engine had not always been conducted at the appropriate time intervals. However, it was not possible to determine exactly when the corrosion started and propagated.

After the engine lost power, the decision by the pilot to conduct a forced landing rather than turn back to the departure runway minimised the risk of loss of control during the forced landing.

The pilot was not wearing an upper torso restraint (UTR), but fortunately was not injured on this occasion. However, by not wearing his UTR, he significantly exposed himself to unnecessary injury risk.

What's been done as a result

The operator advised that it intends to direct pilots to wear upper torso restraints and that this requirement will be incorporated into its training and induction schedule.

Safety message

Corrosion was able to form within the carburettor that was not prevented or detected. This occurrence highlights the importance of following the maintenance program for the aircraft. Particularly in this case, this included draining and flushing the carburettor at its periodic inspection.

When available, upper torso restraints should be worn. While the pilot was uninjured during the accident, a substantial amount of research has shown that wearing an upper torso restraint significantly reduces the risk of injury compared to lap belts only.

Download final report
[Download  PDF: 1.69MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety actions

Sources and submissions

General details
Date: 06 January 2019   Investigation status: Completed  
Time: 1045 AEDT   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): near Tooradin Airfield   Investigation phase: Final report: Dissemination  
State: Victoria   Occurrence type: Engine failure or malfunction  
Release date: 31 January 2020   Occurrence category: Accident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 182G  
Aircraft registration VH-DGF  
Serial number 18255755  
Operator Skydive South East Melbourne  
Type of operation Sports Aviation  
Sector Piston  
Damage to aircraft Substantial  
Departure point Tooradin Airfield, Victoria  
Destination Tooradin Airfield, Victoria  
Last update 28 April 2020