Aviation safety investigations & reports

Engine power loss and collision with terrain involving Piper PA-32-300, VH-CWK near Moorabbin Airport, Victoria on 22 June 2021

Investigation number:
AO-2021-024
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

Download Final report
[Download  PDF: 860KB]
 

What happened

On the morning of 22 June 2021, the pilot of a Piper PA-32-300 Cherokee Six, registered VH‑CWK, prepared for a private flight at Moorabbin Airport. The pilot was the only occupant and intended to conduct several circuits during the flight to maintain experience in the aircraft type.

Between 1129 and 1200 Eastern Standard Time, the pilot conducted an engine run up and completed 3 circuits using runway 35 right without any incident or abnormal engine indications.

At 1200, as the aircraft climbed through 505 ft above ground level to complete a fourth circuit fuel flow to the engine significantly reduced and within 12 seconds, the engine lost power.

Soon after the engine power loss, the aircraft commenced descending. The pilot identified one of few clear areas available for a forced landing and manoeuvred the aircraft towards that area. As the aircraft approached the selected landing area, the pilot recognised that insufficient height remained to clear trees along the southern edge of the selected landing area. The aircraft impacted the trees before colliding with rising ground about 35 m beyond the trees. The aircraft was destroyed, and the pilot sustained serious injuries.

What the ATSB found

The ATSB found that as the aircraft climbed upwind from the departure runway, fuel flow reduced and the engine lost power. Despite extensive examination, the reason for the fuel flow reduction could not be determined.

It was also identified that the incorrect engine variant for the aircraft serial number was inadvertently fitted to the aircraft. This did not affect the operation of the aircraft or contribute to the power loss.

Safety message

This accident highlights the challenges pilots face when confronted with a loss of engine power at low level and with few suitable forced landing areas within the glide capability of the aircraft.

Pilots can best mitigate the effects of a power loss by forward planning, which reduces your mental workload under stress, and always maintaining control of your aircraft. Maintain glide speed and use no more than a moderate bank angle to avoid entering a stall and/or spin. During the forced landing, aim to arrive at the ground with wings level and the aircraft level with the ground, which improves your prospects of survivability. The ATSB research publication Managing partial power loss after take-off in single-engine aircraft provides further guidance, which is also applicable to a complete power loss.

The investigation also found that while in this case the fitment of an incorrect engine variant did not contribute to the accident, it underlines the importance of the correct interpretation of the manufacturer’s type certificate documentation. If the guidance is unclear, a maintainer should contact the Civil Aviation Safety Authority or the original equipment manufacturer for clarity on permitted action.

Download Final report
[Download  PDF: 860KB]
 
 
 

The investigation

Summary

The ATSB is investigating the collision with terrain of a Piper PA-32-300 aircraft, VH-CWK, near Moorabbin Airport, Victoria on 22 June 2021.

At 1205, the aircraft had been conducting circuit operations at Moorabbin Airport and collided with terrain approximately 1 km north of the airport at Heatherton.. Emergency services attended the accident site shortly afterwards and rescued the pilot, the sole occupant, from the wreckage. The pilot had been seriously injured and was transported to hospital. The aircraft was destroyed by the impact.

The evidence collection phase of the investigation will include examination of the accident site and wreckage by ATSB investigators, and the collection of other relevant evidence, including recorded data and communications, air traffic control surveillance data, weather information, witness reports, aircraft operator procedures and maintenance records, and interviewing the pilot.

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.

General details
Date: 22 June 2021   Investigation status: Completed  
Time: 1201 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Moorabbin Airport   Investigation phase: Final report: Dissemination  
State: Victoria   Occurrence type: Engine failure or malfunction  
Release date: 14 September 2022   Occurrence category: Accident  
Report status: Final   Highest injury level: Serious  

Aircraft details

Aircraft details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-32-300  
Aircraft registration VH-CWK  
Serial number 32-7840052  
Type of operation General Aviation  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Moorabbin, Victoria  
Destination Moorabbin, Victoria  
Last update 21 September 2022