The ATSB has issued a safety advisory notice urging Cessna 206 operators to consider fitting an approved emergency exit modification or removing a middle row seat to allow better passenger emergency egress.
The notice stems from the investigation of a landing accident involving a Cessna U206F, where passengers were unable to exit from the rear cargo door after the accident due to the aircraft’s flaps being extended.
The ATSB’s final report into the 1 September 2024 accident notes the aircraft was being used for a short local area flight out of a private airstrip near the WA wheatbelt town of Moora, with a pilot and five passengers on board.
During the landing, which followed a non-standard approach, the aircraft bounced twice.
The pilot attempted a go-around, however the flap was set incorrectly and the aircraft was unable to gain height. The right wing struck the ground before the aircraft touched down on its landing gear, causing it to deviate from the runway and come to rest in an adjacent paddock.
After the aircraft came to a stop, the pilot and the passengers in the front and middle rows exited through the pilot’s forward, left cabin door.
However, the two passengers in the rear row were unable to operate the rear ‘clam shell’ cargo door as their emergency exit, with the forward half of the door blocked by the right wing’s flap, which was still extended.
The pilot was unable to retract the flaps, and the rear row passengers – a child and an older person – had to climb over the middle row of seats to exit the aircraft via the forward left cabin door.
“When the Cessna 206’s flaps are extended 10° or more, this prevents the cargo door from being opened, other than by following a multi-step process that is not intuitive or simple,” explained ATSB Chief Commissioner Angus Mitchell.
“Fortunately, in this case no injuries occurred, but this scenario has resulted in fatal injuries in the past due to the increased time taken to evacuate the aircraft, which impacts post-impact survivability, particularly if there is a fire or a water ditching.”
Mr Mitchell said Cessna 206 operators should consider either the removal of a middle row seat to improve rear seat occupants’ access to the pilot’s forward left cabin door, or the fitment of an approved Cessna 206 emergency exit modification that allows the immediate and unobstructed use of the rear cargo doors during an emergency exit.
“The removal of a middle row seat or fitment of an approved cargo door modification can improve the survivability for occupants of the Cessna 206,” he said.
Following a fatal accident in 2018, the Canadian aviation regulator, Transport Canada, now requires Canadian Cessna 206 operators to either remove a middle row seat, or to fit an STC‑approved modification that either provides an additional exit or modifies the cargo door such that extended flap does not block its opening.
“The ATSB strongly encourages Australian operators of Cessna 206 aircraft with the double cargo door, to review the Transport Canada mandated changes, and consider implementing the improvements for the survivability for passengers during emergency egress in their Cessna 206s.”
Mr Mitchell said the ATSB investigation also highlighted the importance of passenger emergency briefings.
“The investigation found that the operator’s pre-flight passenger briefing did not include the demonstration of, and pilots were not trained how to operate, the emergency exit via the cargo door with the flaps extended,” he said.
“This highlights the importance of Cessna 206 pre-flight passenger briefings incorporating a demonstration of the limitations of the cargo door as an emergency exit with the flaps extended.”
Consequently, the ATSB has issued a second safety advisory notice to Cessna 206 operators, advising them to ensure passengers have a thorough understanding of the use of emergency exits.
"The ATSB advises Cessna 206 pilots and operators that due to the difficulties occupants have encountered egressing the rear cargo door to ensure they are familiar with CASA‑issued Airworthiness Bulletin 52‑006, and ensure passengers are provided with a thorough safety briefing demonstrating the cargo door emergency egress when the wing flaps remain in the extended position," Mr Mitchell concluded.
Read the final report: Collision with terrain during go-around involving Cessna U206F, VH-TDQ, 39 km south-east of Moora, Western Australia, on 1 September 2024