On 12 November 2012, Beechcraft Bonanza VH-SQI, was departing Kumarina Roadhouse airstrip, Western Australia for a fire reconnaissance flight. On board were the pilot and one passenger.
As the aircraft accelerated for takeoff, the forward cabin door next to the passenger opened. The pilot elected to continue the takeoff and return to land at Kumarina, to secure the door.
To expedite the circuit and landing, the pilot left the aircraft in the take-off configuration, apart from retracting the landing gear. The pilot flew a lower and tighter circuit than normal.
As the aircraft was flared for landing, the pilot realised he had forgotten his downwind and pre-landing checks. These included extending the landing gear. The aircraft landed with the wheels up and skidded to a halt on the runway.
This report highlights the risks associated with the distraction of an abnormal event during flight, and looks at Canadian research statistics from similar events at:
At about 0825 Eastern Standard Time1 on 9 November 2012, a student pilot and instructor departed Gold Coast/Coolangatta Airport, Queensland, for a training flight in VH-HBB, a SOCATA TB‑20 Trinidad. The student pilot had passed the general flying progress test (GFPT)2, but the student had recently acquired the Trinidad aircraft and was under the supervision of an instructor to undergo conversion training for the new aircraft.
The student had primarily carried out their previous flight training on Cessna 172 aircraft (172) that had fixed landing gear and a fixed pitch propeller. The Trinidad differed from the 172 in a number of ways that included having retractable landing gear and a variable pitch, constant speed propeller. Those features were considered to be ‘special design features’ and the conversion training being undertaken included endorsements for those special design features. The flight on 9 November was the student pilot’s sixth and the instructor’s seventh flight in the aircraft, having accumulated 7.8 hours and 8.9 hours, respectively, during the previous flights.
On the day, the aircraft departed from Coolangatta to the north before turning south. The aircraft was initially being tracked by the air traffic control radar, but at about 60 km south-south-west of Coolangatta the aircraft flew outside radar coverage (Figure 1).
Figure 1: Flight path of VH-HBB
Source: Google Earth
The path taken by the aircraft following the loss of radar coverage was unknown. However, at about 0845, the pilot broadcast on the Lismore common traffic advisory frequency (CTAF) that they were about 8 NM (15 km) north of Lismore Airport, New South Wales (NSW) and inbound to conduct circuits3 on runway 33 at Lismore. Reports indicated that the aircraft had completed a number of circuits prior to the accident.
At about 09154, a number of witnesses travelling along the Bruxner Highway between Lismore and Casino, NSW observed the aircraft make an abrupt steep left bank before pitching nose down and rapidly descending. The aircraft’s nose was then observed to have been raised and its rate of descent reduced before crossing the Bruxner Highway at very low height. The aircraft impacted the ground in a paddock adjacent to the highway. Both occupants on board the aircraft were fatally injured.
The Australian Transport Safety Bureau (ATSB) initiated an investigation and attended the accident site. The ground impact marks observed by the ATSB indicated that the aircraft impacted the ground in a left wing-low attitude with the nose of the aircraft level, or slightly nose-up. The left main and nose landing gear separated from the aircraft and it continued to skid along the ground. The aircraft continued through a wire fence, where the fuel escaped from the tanks and caught alight, before the right wing impacted the ground and the aircraft flipped over, coming to rest inverted about 170 m after the initial impact point (Figure 2). The engine separated from the fuselage during the impact sequence and came to rest about 13 m beyond the main aircraft wreckage.
Figure 2: Accident site
Source: NSW Police
An intense fuel-fed fire continued to burn around the aircraft following the accident. That fire destroyed a substantial amount of the aircraft structure (Figure 3).
The investigation is continuing and will include:
examination of the engine and propeller
examination of the experience of the student and instructor
assessment of the aircraft’s handling qualities.
The evidence will be analysed and a final report completed detailing the findings of the investigation.
Figure 3: Main wreckage
Source: ATSB ______________
[1] Eastern Standard Time was Coordinated Universal Time + 10 hours.
[2] A GFPT indicates that a pilot has attained a standard in the safe control and handling of an aircraft. The test does not assess flight navigation beyond an ability to fly in the vicinity of the departure aerodrome and the approved training area. The pilot remains a student pilot until a private or a commercial flight test has been passed.
[3] A standard rectangular traffic pattern flown around an aerodrome when taking off from, or landing on a runway.
[4] The local time at Lismore was 1015 Eastern Daylight-saving Time (UTC+11).
The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB’s understanding of the occurrence as outlined in the web update. As such, no analysis or findings are included in this update.
Update 12 November
ATSB investigators began the on-site phase of the investigation on Saturday 10 November.
The team has been liaising with the local police to secure perishable evidence, including the pattern of the wreckage and marks from impact.
The ATSB has retained the aircraft’s engine for later technical examination.
Over the next few days, the team will be:
interviewing witnesses
meeting with the aircraft operator
retrieving aircraft and pilot records.
The on-site wreckage examination will be completed later today and the ATSB aims to finalise the investigation by November 2013.
This page will be updated as significant information comes to hand.
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9 November 2012
The ATSB is investigating an accident involving a SOCATA TB-20 that collided with terrain at Lismore on 9 November 2012.
The aircraft was seen to bank left and impact the ground. It was destroyed by fire and the two people on board died as a result of the accident.
The ATSB has sent a team of investigators to begin the on-site phase of the investigation.
Investigators will be:
examining the wreckage for evidence
interviewing witnesses and aircraft operator
reviewing maintenance documents.
The ATSB will also review the pilot’s training and experience and collate and analyse witness information.
If you have any information about the accident please call the ATSB on 1800 020 616.
Summary
What happened
On 9 November 2012, a student and instructor departed Gold Coast Airport, Queensland for a training flight in a SOCATA TB 20, registered VH-HBB, to Lismore Airport, New South Wales. This included circuit training as part of the student’s conversion to the aircraft type. On their fifth circuit, and while making a left turn from downwind to base, the aircraft aerodynamically stalled, and the left wing dropped steeply. A recovery was commenced, but the aircraft collided with terrain in a paddock to the east of the Bruxner Highway, about 3 km south of Lismore Airport. Both occupants received fatal injuries, and the aircraft was destroyed by the impact and an intense fuel-fed, post-impact fire.
What the ATSB found
The ATSB found that while making a left turn in the circuit, an aerodynamic stall occurred, resulting in a significant left-wing low and nose-down attitude in close proximity to the terrain. The instructor was unable to prevent the stall from occurring due to either insufficient warning or available time to react. Although it appeared that a stall recovery was commenced, the aircraft stalled at an altitude from which they were unable to fully recover to controlled flight before the aircraft collided with the terrain.
The ATSB also found that the aircraft’s engine contained crankcase through bolts from a different engine manufacturer that were installed in the engine prior to the aircraft’s importation into Australia and were probably unapproved for use in that engine. Although these bolts did not contribute to the accident, their installation meant that the continued safe operation of the engine could not be assured.
Safety message
The accident highlights the need for pilots to minimise the risk of aerodynamic stall, particularly when in proximity to the ground, such as during take-off and landing.
In addition, aircraft owners and maintainers should ensure that all parts fitted to their aircraft are appropriately approved for the application. The use of unapproved parts means that aircraft safety cannot be assured.
On 5 November 2012, a Hawker B200 aircraft, registered VH-FDT (FDT), departed Bundaberg on an aeromedical retrieval flight to Brisbane, Queensland. On board the aircraft were the pilot, the flight nurse and two patients.
Between 1556 and 1607 Eastern Standard Time, Brisbane Centre and Brisbane Approach attempted to contact FDT on a number of occasions, with no response received.
The nurse also became concerned as she had not yet sighted the geographic features she normally observed. The nurse turned towards the pilot and observed that his chin was slumped onto his chest, and he was not alert. The nurse attempted to arouse the pilot, at which time the stall warning alarm activating. The pilot regained alertness and initiated recovery actions.
The aircraft landed at Brisbane at 1617.
Drug and Alcohol Management Plan (DAMP) testing was conducted, which returned a positive reading for an illicit substance, which had affected the pilot’s sleep cycle.
Flying an aircraft is a complex, demanding and challenging activity, which requires a high level of cognitive functioning and psychomotor skills. The significant performance impairments associated with drug use are widely recognised. Consequently, the use of drugs by pilots can adversely affect their ability to safely operate an aircraft.
On 7 November 2012, at about 1000 Eastern Standard Time a Cessna 172N registered VH-JGR (JGR) departed Archerfield Airport, Queensland on a training flight. The purpose of the flight was to conduct solo pre-test revision, prior to the pilot performing the Private Pilot Licence (PPL) flight test. The aircraft was booked for 2 hours. During the flight, the aircraft impacted terrain and was substantially damaged. The pilot was the only person on board and suffered severe injuries as a result of the accident and was airlifted to hospital.
The aircraft activated air switch indicated that the aircraft was airborne for approximately 45 minutes prior to the accident, placing the time of the accident about 3 hours prior to the aircraft being located.
This accident highlights the importance of lodging a Search and Rescue Time (SARTIME), Flight Plan or Flight Note with a responsible person, to eliminate any major delays in commencing a search. Failure to do this means that you are relying on being able to get an emergency call out, using your Emergency Locator Transmitter (ELT) to alert the Rescue Coordination Centre Australia (RCC) or relying on someone noticing that you have gone missing.
On 26 October 2012, a Bombardier DHC-8-402 aircraft, registered VH-LQG, departed Perth on a scheduled passenger service to Geraldton, Western Australia. Shortly after takeoff, at about 700 ft, the captain observed a weather balloon above, in his 1 o’clock position. The captain advised the first officer, who immediately initiated a slight left turn. The balloon was observed to pass about 10-20 m laterally from the right wingtip. The captain advised air traffic control.
On 28 October 2012, at about 1410 Eastern Daylight-saving Time, an unmanned airship (callsign Airship 11) departed Keysborough, Victoria on a 30 minute test flight to assess the airship’s centre of gravity and manoeuvrability characteristics. The airship was controlled via a portable radio-controlled transmitter.
The crew planned to operate the flight below 200 ft above ground level and within 100-200 m of their location, with the airship remaining clear of the Moorabbin Class D control area.
Shortly after takeoff, the crew noticed that the airship’s centre of gravity was rearward, resulting in a nose-up attitude. About one minute later, when it was at about 130 ft, the pilot realised that he could not turn the airship to the left. The crew had lost control of the airship although the data link was still functioning.
Attempts to contact the Moorabbin control tower were unsuccessful. At about 1428, the air traffic controllers at Moorabbin observed the airship about 2 NM to the south-east at about 1,000 ft. At about 1500, the airship landed on the roof of a commercial building, sustaining minor damage.
As a result of this occurrence, the airship operator is taking the following safety actions:
source an airship from another manufacturer;
develop a safe method for tethered air testing;
develop a simulator for a small X-tail airship;
locate a suitable site for flight testing away from populated areas;
install the ground control station in the support vehicle;
On 31 October 2012, the pilot of a Robinson R22 helicopter, VH-HOA, was conducting mustering operations at Innamincka Station, South Australia on a hot, cloudless day.
The helicopter had been assisting ground personnel move a large mob of cattle through sandy and swampy terrain. The pilot was tasked with flying a low-level east-west grid pattern well behind the main herd, checking for stray cattle.
The pilot’s visibility through the windscreen had deteriorated during the day, due to a build-up of dust, sand and mud. During his final run, the pilot conducted a right turn from west to east over the edge of Lake Marradibbadibba. Although wearing sunglasses, the pilot received significant sun-glare from the water. He became disoriented and did not detect a rate of descent. The helicopter contacted the water and sank. The pilot exited the helicopter without injury and swam to shore.
The effect of sun-glare when relying on visual cues has contributed to a number of accidents, and has been documented in US Federal Aviation Administration research report Sunlight and its association with aviation accidents.
On 26 October 2012, a Piper PA-39 (Twin Comanche) aircraft, registered VH‑MMN (MMN), was landing at the Innamincka Township aeroplane landing area (ALA), South Australia. On board the aircraft were the pilot and a passenger.
MMN joined the circuit, and when on the downwind leg, the pilot noted that the windsock was indicating a strong crosswind. As a precaution, the pilot elected to increase the aircraft’s airspeed for the approach by about 5 knots and selected ½ flaps (about 15 degrees).
The pilot turned the aircraft onto final about 200 ft higher than normal. At that time, the windsock was showing a 15 kt crosswind, from the south-west. The pilot focused on the crosswind and ensured that the aircraft remained aligned with the runway.
During the landing, at about 100 ft above the runway, the flare was commenced. The aircraft floated and touched down about a quarter the way along the runway. The pilot reduced the throttle setting to the idle position and applied light braking.
When the aircraft was about half way along the runway, the pilot realised that the aircraft’s speed was too fast and he applied full braking. The pilot determined that it was too late to commence a go‑around. He reported that the braking appeared to be ineffective due to the surface of the runway and the aircraft continued beyond the runway end. The left landing gear struck a depression, and then the aircraft spun to the left and came to rest in a 1 m deep gully. The pilot and passenger exited the aircraft, the pilot received a minor injury whille the passenger was uninjured. The aircraft sustained serious damage.
This accident demonstrates the importance of assessing the operational and environmental conditions at the time in order to determine the most suitable landing type. Pilots should also establish a decision point along the runway at which a go-around should be initiated if the requirements for a safe landing can no longer be met. Additionally, it highlights the benefits of using all available resources, including persons on the ground, for gathering information on the actual conditions.
On 25 October 2012, at about 1510 Eastern Daylight-saving Time a Helicopters Guimbal Cabri G2 (Cabri G2) helicopter, registered VH-CDU (CDU), departed Bankstown Airport New South Wales on a local training flight. On board the helicopter were an instructor and student. The instructor proceeded to demonstrate the recovery from low main rotor RPM in the hover. During the demonstration the helicopter began to rotate to the left. The instructor opposed the rotation with full right pedal however the rotation could not be stopped, and the helicopter was landed heavily. There was minor damage to the helicopter as a result of the incident and the instructor and student were able to exit the helicopter without injury.
As a result of this incident the helicopter manufacturer is preparing a service letter with the intention of preventing training sequences being performed that are inappropriate for the helicopter type.
On 29 October 2012, a Cessna 172N, registered VH-TKI, was being operated on a flight from Coldstream, Victoria to a private airstrip at Bagshot, Victoria, with a pilot and two passengers on board. The private flight was being conducted to position the aircraft for maintenance.
The aircraft arrived at the airstrip at about 1300 Eastern daylight-saving time. A witness, who was located at the southern end of the airfield, observed a Tecnam aircraft land from the south as the Cessna 172 entered the circuit. The Tecnam landed and backtracked to a maintenance facility located on the southern end of the airstrip.
The pilot of the Cessna overflew the strip then conducted a right circuit to land. The passenger seated behind the pilot stated that all the occupants were focussing their attention on the Tecnam on the airstrip during the circuit and final approach.
The witness at the airfield stated that, as the Tecnam cleared the airstrip, the Cessna was on a short final approach. He saw the aircraft contact a powerline, located at the southern end of the airfield. The aircraft rotated over the powerline, significantly reducing its forward speed and causing it to impact the runway in an almost inverted attitude.
The aircraft came to rest inverted, and a post-impact, fuel-fed fire initiated at the wing roots and destroyed the aircraft (Figure 1). Witnesses reached the aircraft quickly and assisted the occupants. However, the front seat passenger was fatally injured, the pilot was seriously injured and the rear seat passenger sustained minor injuries.
Figure 1: Accident site of the Cessna 172, VH-TKI
Source: ATSB
Examination of the aircraft showed that its nose landing gear contacted the powerline. The powerline was located 7 m above ground level and about 140 m from the end of the 900 m long landing strip (Figure 2).
The powerline had no markers fitted, nor were any required under the current Australian Standards for private landing strips. The owner of the landing strip advised that he routinely provided advice to pilots using the airstrip of the location of the powerline and of the need to land a significant distance down the airstrip to avoid the wire if landing from the south.
Figure 2: High level view of runway
Source: Google
Investigation activities
The on-site phase of the investigation concluded on 2 November 2012. The investigation is continuing and will include analysis of the circumstances surrounding the wirestrike including, but not limited to:
the location of the powerline in relation to the airstrip
requirements for powerline markers
pilots’ knowledge of the powerline’s location
pilot distraction
pilot visibility
pilot experience
the circuit flown by the pilot.
The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB’s understanding of the occurrence as outlined in the web update. As such, no analysis or findings are included in this update.
Update 2 November 2012
The ATSB team has now completed the on-site stage of the investigation. The team has:
examined the wreckage
interviewed one of the passengers and the aircraft owner
reviewed the aircraft’s maintenance logs.
The ATSB’s investigation will now continue off-site.
This page will be updated as significant information comes to hand.
The ATSB aims to finalise its investigation within 12 months.
Subscribe now to receive news and information from the ATSB and follow us on Twitter @atsbinfo for investigation updates.
Update 30 October 2012
The ATSB team is on-site:
coordinating activities with local police and Coronial staff
interviewing witnesses
conducting initial site assessment
planning site activities.
29 October 2012
The ATSB has sent a team of investigators to begin the on-site phase of the investigation. The team comprises experts in engineering and aircraft operations. It is expect they will arrive mid-morning (Tuesday 30 October) and spend three to five days at the accident site.
As part of the on-site investigation, the team will be:
examining the wreckage for evidence
interviewing witnesses and aircraft operator
reviewing maintenance documents.
The ATSB will also review the pilot’s training and experience and collate and analyse witness information.
If you have any information about the accident please call the ATSB on 1800 020 616.
Summary
What happened
On 29 October 2012, a Cessna 172N, registered VH-TKI (TKI), was being operated on a visual flight rules (VFR) flight from Coldstream to a private aircraft landing area (ALA) at Bagshot, Victoria, with a pilot and two passengers on board.
A witness at the airfield stated that as TKI approached short final on the approach, the aircraft contacted a powerline located at the southern end of the airfield. The powerline significantly reduced the aircraft’s forward speed, causing it to rotate about its nose and impact the airstrip in an almost inverted attitude. A post-impact, fuel-fed fire initiated at the wing roots almost immediately and witnesses assisted the aircraft occupants from the aircraft. However, the front-seat passenger was fatally injured, the pilot was seriously injured and the rear seat passenger sustained minor injuries.
What the ATSB found
Examination of the aircraft showed that its nose landing gear contacted the powerline. The powerline was located 8 m above ground level and about 140 m south of the displaced threshold of the landing strip.
The ATSB found that the pilot was aware of the powerline, but that his recollection was that they were closer to the tree line in the undershoot to the landing strip. In addition, a lack of adequate displaced threshold markings and the mown undershoot area led him to believe that the entire strip was useable for landing. This combined with the inherent difficulty of visually detecting wires and the distraction of another recently-landed aircraft on the airstrip to reduce the likelihood of the pilot detecting the wire.
No high visibility devices were attached to the powerlines, nor were they required to be under the current Australian Standards.
What's been done as a result
In response to this accident, the owner of the ALA has made significant changes to the runway markings, landing permission procedures affecting operations at the ALA and the available safety and firefighting equipment. In addition, markers have been erected near the powerline.
Safety message
Aeroplane landing area owners can help manage the risk of collisions with obstacles by assessing their airstrips against the guidance in Civil Aviation Advisory Publication (CAAP) 92-1(1) Guidelines for Aeroplane Landing Areas. Such risk assessments should explicitly consider the needs of first time users of the ALA.
Operational risk can also be reduced by pilots ensuring sufficient time to make appropriate decisions including, if in doubt, an early decision to go around. Pilots should also ensure that everyone in their aircraft is wearing seatbelts correctly, affording the best chance of survival in case of an accident.
