Safety summary
What happened
At about 1710 on 27 January 2012, a De Havilland Aircraft Pty Ltd DH-82A Tiger Moth aircraft, registered VH-GVA, took off from Maryborough Airport, Victoria, with two people on board.
Immediately after lift-off, the aircraft was observed to have a partial, intermittent power loss. The pilot continued the flight with the aircraft maintaining altitude or climbing slightly. At the upwind end of the runway, the aircraft made a climbing left turn before stalling and descending. The aircraft impacted the ground, and the occupants received fatal injuries.
The aircraft was seriously damaged by the accident forces and post-impact fire.
What the ATSB found
The partial engine power loss was probably a result of a partial blockage of the aircraft’s fuel cock. Although sufficient runway remained ahead to allow a safe landing, the flight was continued under limited power without gaining sufficient height to clear trees beyond the runway. Approaching the trees the aircraft climbed, lost airspeed, stalled and collided with terrain. There would have been a safer outcome had the pilot immediately landed the aircraft straight ahead.
Safety message
This accident illustrates several of the points made in the ATSB’s research report
Inquest
Response to Inquest Findings
The Coroner’s Court of Victoria, without holding an inquest, recently made findings into a 2012 fatal De Havilland Aircraft DH-82A (Tiger Moth) aircraft at the Maryborough Airfield.
The Coroner adopted the Sequence of Events as set out in the Australian Transport Safety Bureau final report in relation to how the accident occurred and incorporated into his finding those of the ATSB as to the possible cause of loss of power.
ATSB Investigations and Coronial Inquiries
Inquests are separate to ATSB investigations. In this matter the respective authorities largely agree on what the safety issues are that the industry needs to take account of.
The ATSB's report can be downloaded by clicking on the link: AO-2012-017 Feedback can be provided via the website.
The Coroner's report can be obtained from the Coroner's Court of Victoria. Contact details are available at: www.coronerscourt.vic.gov.au/utility/contact+us/ Queries regarding the Coroner's findings should be directed to the Coroner's Court of Victoria.
Occurrence summary
| Investigation number | AO-2012-017 |
|---|---|
| Occurrence date | 27/01/2012 |
| Location | Maryborough |
| State | Victoria |
| Report release date | 04/10/2012 |
| Report status | Final |
| Investigation level | Systemic |
| Investigation type | Occurrence Investigation |
| Investigation status | Completed |
| Mode of transport | Aviation |
| Aviation occurrence category | Fuel starvation |
| Occurrence class | Accident |
| Highest injury level | Fatal |
Aircraft details
| Manufacturer | de Havilland Aircraft |
|---|---|
| Model | DH-82 |
| Registration | VH-GVA |
| Serial number | 1014 |
| Operation type | Private |
| Departure point | Maryborough, Vic. |
| Destination | Maryborough, Vic. |
| Damage | Destroyed |