Aviation safety investigations & reports

Collision with water involving Textron Aviation Inc. (Cessna) 206, VH-AEE near Happy Valley, Fraser Island, Queensland on 29 January 2020

Investigation number:
AO-2020-010
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

Download Final report
[Download  PDF: 1.37MB]
 

What happened

At 1322 Eastern Standard Time, on 29 January 2020, a Cessna Aircraft Company U206G, registered VH-AEE and operated by Air Fraser Island with two pilots onboard, was being used for landing emergency procedure training on a beach aircraft landing area (ALA) on Fraser Island, Queensland.

Just after touching down, the aircraft veered significantly to the left, toward the sea. The training pilot took control of the aircraft and conducted a go-around. Once airborne it was identified that the rudder was jammed in the full‑left position and the pilot had to apply full opposite aileron to maintain control. The engine subsequently stopped and the aircraft collided with water. The pilots escaped the aircraft and swam to shore. The aircraft was destroyed.

What the ATSB found

The ATSB found that, following touchdown, a section of the nose landing gear attachment failed, resulting in the rudder becoming jammed in the full‑left position. Due to the aircraft’s significant deviation towards the water, a go-around was initiated. While there was only a short timeframe to make the decision to abort the landing, it resulted in flight over water with significantly reduced aircraft controllability that required uncoordinated flight control inputs to control the aircraft.

It was also identified that fuel starvation, due to either the uncoordinated flight or damage associated with the nose gear failure, led to the engine losing power at a height too low for recovery and the aircraft collided with water.

The ATSB also identified two safety issues associated with the Cessna 206 that, while not contributory to this accident, can lead to fatal consequences in the event of a ditching.

Firstly, the Cessna 206 procedure for ditching and forced landing stated that the flaps were to be extended to 40°. While that permitted the aircraft to land at a slower speed, it also significantly restricts emergency egress via the cargo door. However, there is no warning about that aspect in the ditching or forced landing pilot’s operating handbook emergency procedures.

In addition, the Cessna 206 with the cargo door does not meet the aircraft certification basis for the design of cabin exits, due to the complexity associated with opening the cargo door if it is blocked by the flaps. This significantly hampers emergency egress and has previously resulted in fatalities.

What has been done as a result

The ATSB has recommended that Textron Aviation take safety action to address the procedure for ditching and forced landing in the pilot operating handbook for the Cessna 206, to ensure pilots are aware that extending the flaps beyond 10° will significantly restrict emergency egress via the cargo door.

The ATSB also recommends that the United States Federal Aviation Administration and the Civil Aviation Safety Authority take safety action to address the certification basis for the design of the cargo door in the Cessna 206, as wing flap extension beyond 10° will block the forward portion of the rear double door, significantly hampering emergency egress. 

In addition, and as a result of this accident, the operator has changed their procedures to specify that during emergency procedure training on the beach, no non-company vehicles are permitted to operate within the runway complex. They have also reassessed the company hazard register and included brake failures.

Safety message

This occurrence highlights the issue of evacuation through the cargo door when the flaps are extended in the Cessna 206. Pilots should be aware that lowering the flaps will block this exit and significantly increase the difficulty of opening the door. Consequently, all passenger pre‑flight briefings should include a practical demonstration of how to open a partially‑obstructed cargo door. Additionally, in the event that a ditching is required, pilots should consider not extending the flaps.

Furthermore, in 2009, research by the Transport Safety Board of Canada found that in the previous 20 years, where an aircraft had collided with water, 70 per cent of fatalities were caused by drowning. That statistic reflects the inherently disorientating nature of underwater exit from an often-inverted aircraft.

Transport Canada released TP 2228E-18 (04/2003), an ‘underwater egress’ safety guide which was forwarded to all Canadian operators of passenger carrying operations operating on water. This guide was to be provided to passengers before flight to increase their likelihood of survival in the event of a ditching.

Download Final report
[Download  PDF: 1.37MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

About the ATSB

Safety Issues

Go to AO-2020-010-SI-01 - Go to AO-2020-010-SI-02 - Go to AO-2020-010-SI-02 -

Cessna 206 emergency procedures

The Cessna 206 procedure for ditching and forced landing states that the flaps are to be extended to 40°. While that permits the aircraft to land at a slower speed, it also significantly restricts emergency egress via the cargo door. However, there is no warning about that aspect in the ditching or forced landing pilot’s operating handbook emergency procedures.

Safety issue details
Issue number: AO-2020-010-SI-01
Status: Open – Safety action pending

Cabin exit design criteria (Issue owner: United States Federal Aviation Administration)

Cessna 206 aircraft that feature a rear double cargo door do not meet the aircraft certification basis for the design of cabin exits. Wing flap extensions beyond 10° will block the forward portion of the rear double cargo door, significantly hampering emergency egress. This has previously resulted in fatalities.

Safety issue details
Issue number: AO-2020-010-SI-02
Status: Open – Safety action pending

Cabin exit design criteria (Issue owner: Civil Aviation Safety Authority)

Cessna 206 aircraft that feature a rear double cargo door do not meet the aircraft certification basis for the design of cabin exits. Wing flap extensions beyond 10° will block the forward portion of the rear double cargo door, significantly hampering emergency egress. This has previously resulted in fatalities.

Safety issue details
Issue number: AO-2020-010-SI-02
Status: Open – Safety action pending
General details
Date: 29 January 2020   Investigation status: Completed  
Time: 13:22 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): near Happy Valley, Fraser Island   Investigation phase: Final report: Dissemination  
State: Queensland   Occurrence type: Collision with terrain  
Release date: 08 July 2021   Occurrence category: Accident  
Report status: Final   Highest injury level: Minor  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model U206G  
Aircraft registration VH-AEE  
Serial number U20605226  
Operator Beasts Company  
Type of operation Business  
Sector Piston  
Damage to aircraft Destroyed  
Departure point near Happy Valley, Queensland  
Destination near Happy Valley, Queensland  
Last update 08 July 2021