Pegasus Quantum, Emkaytee (50 km south-east of Darwin), Northern Territory, on 30 June 1990

Summary

Circumstances:

The pilot was taking part in the activities of an Australian Ultralight Federation (AUF) club which used the strip for its home base. The pilot was apparently neither a member of the AUF nor the Australian Hang Glider Association. He had only owned the aircraft for about six weeks. Witnesses reported that their attention was drawn to the accident aircraft by the revving of the engine by the pilot. The aircraft at this point was over the strip at approximately 1300 feet above ground level. The pilot was then seen to manoeuvre the aircraft into a steep, near vertical climb. From this point, the aircraft reportedly lost flying speed and flipped over three times. The wings of the aircraft were then seen to fold and separate from the rest of the aircraft as the engine noise stopped, and the aircraft fuselage spiralled into the ground. Investigations into the pilot's background revealed consistent reports of his habit of showing off and performing manoeuvres close to the performance limits of the aircraft he was flying. He was reportedly also seen to perform manoeuvres with inadequate margins of safety and had allegedly been cautioned about his attitude to flying by a principal of the AUF club and the property owner. Engineering investigation of the wreckage showed that all failures of the aircraft structure had occurred as a result of overload or impact forces.

Significant Factors:

The following factors were considered relevant to the development of the accident:

1. The pilot exceeded the design performance limits of the aircraft.

2. Inflight breakup due to pilot-induced overload.

3. Exhibitionist behaviour of the pilot. The accident was not the subject of an on-scene investigation.

Occurrence summary

Investigation number 199000607
Occurrence date 30/06/1990
Location Emkaytee (50 km south-east of Darwin)
State Northern Territory
Report release date 14/09/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Airframe - Other
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Amateur Built Aircraft
Model Pegasus Quantum
Registration Unknown
Sector Piston
Operation type Private
Departure point Emkaytee NT
Destination Emkaytee NT
Damage Destroyed

Beech A36, VH-NYL, Port Hurd (Bathurst Island) NT, 25 November 1988

Summary

The pilot arrived at his destination and joined the circuit. The downwind checks were completed without interruption and the pilot reported that he observed three green gear down lights. The final approach was normal except for a flickering of the alternator warning light during the flare. The pilot completed a "PUF" check on final approach and reported that he again observed three green lights. The aircraft touched down smoothly on the flaps, then the undersurface of the fuselage. Neither the pilot nor the passenger heard the gear warning horn. The gear selector was found to be in the gear down position and the gear actuator circuit breaker had popped. The main gear doors were found to be partly open as if the gear down cycle had started, however, it was reported that there were no scrape marks on the doors to indicate that they had dragged along the strip during the ground slide. The pilot stated that he did not select gear down after the aircraft had landed. During gear retraction and extension checks after the accident the gear was found to work normally, although the gear warning horn worked only intermittently. At the time the pilot flew the downwind leg of the circuit the sun would have been shining onto the instrument panel. It is likely that the gear down lights were illuminated by the sun which would have made it difficult for the pilot to see if there was a gear down indication. Having assumed that the gear down lights were on, he probably formed a false hypothesis that they were indeed on and did not check the gear position indicator thoroughly during his "PUF" check. When the warning horn failed to activate during the flare the last chance to avoid an accident was lost and the aircraft landed with the gear retracted. How the gear selector got into the gear down position is open to conjecture. This accident was not the subject of an on-site investigation.

Occurrence summary

Investigation number 198800737
Occurrence date 25/11/1988
Location Port Hurd (Bathurst Island)
Report release date 13/03/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wheels up landing
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Beech Aircraft Corp
Model 36
Registration VH-NYL
Serial number E227
Operation type Charter
Departure point Darwin NT
Destination Port Hurd NT
Damage Substantial

Osprey 11, VH-JDA, Palm Beach Water Authorised Landing Area, New South Wales, on 29 January 1989

Summary

Circumstances:

The pilot had not previously flown the homebuilt floating hull type amphibian aircraft. The flight was to carry out an evaluation of its water handling characteristics, before continuing with the flight testing for the issue of a Certificate of Airworthiness. The pilot reported that the water conditions were calm with a light easterly breeze blowing. A witness had observed power boats in the area where the aircraft was operating, churning up the water surface. This type of aircraft has a known tendency to "porpoise" in choppy surface conditions. Several high-speed taxi runs were performed, both into wind and crosswind. The pilot reported that the aircraft had a tendency to swing to the left, otherwise operations were normal. He returned to the beach where he had the water rudder alignment checked. After several more high-speed taxy runs the pilot considered that the aircraft was ready for flight. During the take-off and before the aircraft had obtained flying speed, it passed through the wake of a power boat, causing its nose to pitch up and left wing to drop. The pilot released some up elevator pressure and used right aileron to correct the roll. This had little effect in correcting the aircraft attitude before it encountered a second wave, pitching the nose up higher and increasing the roll to the left. The left hand wing float impacted the water causing the aircraft to swing to the left and the nose to drop. This was followed by a severe water loop to the left, which submerged the cabin momentarily and caused the left hand wing float, nose gear door and rudder to separate. Previous flight testing of this type of aircraft had shown that the ideal take-off technique was to maintain the aircraft level, with the elevator control held in the neutral position. This accident was not the subject of an on-scene investigation.

Significant Factors:

The following factors were considered relevant to the development of the accident:

1. The pilot attempted to take-off using a less then optimum control technique.

2. The aircraft was affected by adverse water conditions.

3. A loss of control occurred before the aircraft had reached flying speed.

Occurrence summary

Investigation number 198902539
Occurrence date 29/01/1989
Location Palm Beach Water Authorised Landing Area
State New South Wales
Report release date 09/05/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of control
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Osprey Aircraft
Model Osprey 2
Registration VH-JDA
Serial number N144
Operation type Private
Departure point Palm Beach NSW
Destination Palm Beach NSW
Damage Substantial

Bell 47G2, VH-KHL, Moorabbin VIC, 7 January 1989

Summary

The pilot, who did not hold an instructor rating, was conducting a trial instructional flight. Prior to DEPARTURE, he had briefed the passenger on the functions of the various controls in the helicopter. On the downwind leg of the circuit, the passenger was allowed to handle some of the controls. The aircraft was subsequently placed in a hover at about five feet above the ground, and the passenger was invited to attempt to control the helicopter by use of the anti-torque pedals and the cyclic control. The passenger overcontrolled the aircraft, and the pilot was unable to prevent it from striking the ground in a steep nose-down attitude. Following the impact a fire broke out and destroyed the aircraft. No mechanical fault was subsequently discovered which might have led to the development of the accident. The pilot had undertaken the flight because no qualified instructor had been available at the time the passenger arrived, and he wished to avoid potential embarrassment to the company.

Occurrence summary

Investigation number 198901526
Occurrence date 07/01/1989
Location Moorabbin
Report release date 17/04/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of control
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Bell Helicopter Co
Model 47
Registration VH-KHL
Serial number 2020
Sector Helicopter
Operation type Charter
Departure point Moorabbin VIC
Destination Moorabbin VIC
Damage Destroyed

Beech V35, N8849, Alice Springs, Northern Territory, on 3 May 1990

Summary

Circumstances:

The aircraft had been refuelled to full tanks the night before and a thorough fuel drain check was completed as part of the preflight inspection. No water or impurities were detected. On the day of the accident, the aircraft completed a short local flight of some 25 minutes before departing for its destination. The right tank was used for most of the local flight, so the pilot changed to the nearly full left tank some minutes before joining the circuit. The engine failed immediately after the pilot commenced to turn onto base leg. The fuel selector remained on the left tank, and the engine caught several times by use of the wobble pump but did not continue to run. During the trouble checks, the pilot switched on the left tip tank pump, but this did not help as the pump transfers fuel only to the left main tank. By this stage, the pilot was committed to a forced landing and landed the aircraft about three kilometres short of the threshold. After touchdown, the aircraft crossed a road and passed through a fence before coming to rest on open ground with the nose gear collapsed. An extensive investigation, failed to find a cause for the engine failure. However, the investigation revealed that the pilot did not operate the wobble pump vigorously enough to produce a fuel flow. Operation of the wobble pump more vigorously during the technical investigation, produced a suitable fuel flow from all selected tank positions. The front seat passenger, who was also a commercial pilot, confirmed correct in-flight tank selections.

Significant Factors:

The following factors were considered relevant to the development of the accident:

1. Engine failure for undetermined reason but probably fuel starvation.

2. Pilot was unable to restore power by use of the wobble pump.

3. Inadequate fuel system knowledge.

Occurrence summary

Investigation number 199000585
Occurrence date 03/05/1990
Location Alice Springs
State Northern Territory
Report release date 06/08/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Beech Aircraft Corp
Model 35
Registration N8849A
Serial number N/K
Sector Piston
Operation type Private
Departure point Yulara NT
Destination Alice Springs NT
Damage Substantial

Jodel D11, VH-FTY, Caloundra, Queensland, on 2 September 1990

Summary

Circumstances:

The aircraft was observed to take off from Runway 15 and climb to about 500 feet before commencing a right turn. It then appeared to abruptly change attitude in pitch and roll a few times before adopting a nose low attitude and disappearing behind trees. The aircraft crashed into a shallow swamp and caught fire. On site examination revealed that the aircraft struck the ground in a steep nose and right wing low attitude. The pilot reported that the engine began running roughly and lost power shortly after take-off. An examination found no fault with the engine or carburettor, however, fire damage precluded testing of the magnetos. The aircraft attitude at impact was indicative of it being in a stalled condition.

Significant Factors:

The following factors were considered relevant to the development of the accident:

1. For reason(s) which could not be established, the engine apparently lost power.

2. The pilot lost control of the aircraft.

Occurrence summary

Investigation number 199003098
Occurrence date 02/09/1990
Location Caloundra
State Queensland
Report release date 25/10/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Jodel, Societs Des Avions
Model D11
Registration VH-FTY
Serial number N53
Sector Piston
Operation type Private
Departure point Caloundra QLD
Destination Caboolture QLD
Damage Destroyed

Bell 206B, VH-AKY, Silverwater NSW, 27 October 1984

Summary

A road accident victim required urgent transport to a hospital offering specialist facilities for her particular condition. Road transport by a suitably equipped intensive-care ambulance was not available, and a decision was taken to employ a helicopter. When first contacted, the pilot expressed doubt about the feasibility of using the helicopter because of adverse weather conditions in the area. Some 30 minutes later the pilot was again contacted and requested to undertake the flight. He agreed, subject to weather conditions being suitable, and prepared for the flight from Wollongong to the hospital at Bowral where the patient was being held pending transfer to Sydney. The pilot, accompanied by a crewman and a paramedic, departed Wollongong at 0027 hours local time. As the aircraft approached Bowral, deteriorating weather conditions were encountered. Arrangements were then made through the ambulance radio network for the patient to be transported to Wilton, where the pilot landed shortly after 0100 hours. The patient arrived about 20 minutes later and DEPARTURE for Sydney was made at 0153 hours. When the pilot contacted Sydney Flight Service he was advised that the Control Zone was closed to visual operations because of low cloud. The paramedic considered that the flight should continue because of the patient's condition, and the pilot declared a mercy flight. He was cleared to continue on an emergency basis, with radar directions being provided to assist navigation. The reported cloud base at Sydney Airport was 300 feet, and the night was dark, with no moon. At 0212 hours the pilot reported that the aircraft was running into cloud, and he would hold over Parramatta. No further transmissions were received from the aircraft. Shortly afterwards it was discovered that the aircraft had crashed on the tidal embankment of the Parramatta River. A subsequent detailed examination of the wreckage revealed no mechanical defect or malfunction which might have made an accident inevitable. It was considered that the accident probably resulted from a loss of control of the helicopter during a turn away from an area of low cloud. Neither the aircraft nor the pilot was approved for flight in other than visual conditions, and the pilot probably became disoriented either from the loss of the visible horizon, or by reference to a false horizon. It was evident that he was in the process of regaining control, but insufficient height was available to complete the recovery before impact with the ground.

Occurrence summary

Investigation number 198401413
Occurrence date 27/10/1984
Location Silverwater
Report release date 14/08/1985
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of control
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Bell Helicopter Co
Model 206
Registration VH-AKY
Sector Helicopter
Operation type Aerial Work
Departure point Wilton NSW
Destination Royal North Shore Hospital NSW
Damage Destroyed

Beech A36, VH-MAO, 1.6 km south-east of Medowie, New South Wales, on 11 June 1990

Summary

Circumstances:

During preflight inspection, the pilot visually checked that both fuel tanks were full. About two hours after DEPARTURE, whilst cruising at 7000 feet, the engine suffered a sudden and total loss of power. The pilot immediately selected the left fuel tank but was unable to restore power. As both fuel contents gauges were indicating above half, the pilot reselected the right fuel tank and unsuccessfully continued attempts to restart the engine. The aircraft was force-landed in a swamp, coming to rest intact, but partially submerged. The occupants were able to escape onto the right wing and were rescued by helicopter a short time later. Investigation revealed the right fuel tank cap was unfastened and the tank contained only one litre of fuel. Although the left tank cap was partially unlocked, the tank opening was sealed. That tank contained about 65 litres of fuel. The locking mechanism on both tank caps was extremely stiff and difficult to operate. The unfastened right fuel tank cap had allowed most of the fuel to vent from the tank opening during flight. The engine, which was operating from the right tank, lost power when all fuel was exhausted from the tank. The venting action also caused the bottom of the fuel cell to rise, biasing the fuel contents gauge to indicate about half full. It is believed the engine did not restart with the left tank selected because the pilot did not allow sufficient time for air to be purged from the engine fuel injection system.

Significant Factors:

The following factors were considered relevant to the development of the accident:

1. Both fuel tank caps were extremely difficult to lock closed.

2. The preflight inspection was inadequate and both fuel caps were not correctly locked before flight.

3. Fuel was lost from the right tank in flight.

4. The right fuel gauge incorrectly indicated the quantity of fuel in the right tank.

5. The engine lost power due to fuel starvation.

Occurrence summary

Investigation number 199001992
Occurrence date 11/06/1990
Location 1.6 km south-east of Medowie
State New South Wales
Report release date 15/05/1991
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Beech Aircraft Corp
Model 36
Registration VH-MAO
Serial number E-1226
Sector Piston
Operation type Private
Departure point Coolangatta QLD
Destination Bankstown NSW
Damage Substantial

Bell 206B, VH-TXR, San Michele, 9 km South East of Adaminaby NSW, 7 August 1982

Summary

The helicopter was being used to film a tourist promotion advertisement. The film to be taken involved horse riders on a trail ride, along a ridgeline, backlit by the late afternoon sun. A ground survey of the area had been completed about ten weeks earlier by the pilot and production film crew. Before commencing the filming the film crew completed another ground survey of the area and also an aerial survey in the helicopter. To facilitate the filming a wooden platform was fitted to the landing skids to carry the cameraman and his equipment. The filming runs were flown in a north-westerly direction parallel to the main power line running through the area. Initially the runs were carried out to the east of the power line but subsequently runs were completed to the west of the line. All runs were flown at heights varying between 10 feet and 100 feet agl. During the last filming run the skids struck the two cables of a spur which ran from the main power line at an angle of 92 degrees. The helicopter pitched nose down and struck the ground in a near vertical attitude. On impact the landing skids, platform and cameraman were thrown clear of the main wreckage. Fire broke out immediately and only the pilot survived the combined effects of impact and fire.

The wreckage was completely burnt out. The spur line was strung across a gully over which the helicopter had been flying on the filming runs. The distance between the main line and the first pole on the spur line was 529 m and the line was struck at a point 45 ft agl. Because of the dull grey-brown appearance of the countryside no contrast was provided for the spur line. The filming runs were being made into the late afternoon sun and the pilot and film crew were unaware of the presence of the spur line.

Occurrence summary

Investigation number 198201408
Occurrence date 07/08/1982
Location San Michele, 9 km South East of Adaminaby
Report release date 28/02/1984
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wirestrike
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Bell Helicopter Co
Model 206
Registration VH-TXR
Sector Helicopter
Operation type Charter
Departure point "San Michele" NSW
Destination "San Michele" NSW
Damage Destroyed

Beech B95, VH-UAU, 1 km west of Archerfield, Queensland, on 23 April 1990

Summary

Circumstances:

The flight was scheduled as the last in a series for the pilot under instruction to gain an endorsement on twin engined aircraft. The instructor occupied the right hand cockpit seat and handled the radio communications. He used a handheld microphone which produced transmissions which were scratchy and somewhat garbled. Also, his speech delivery rate was rapid. The Runway 28 Right circuit pattern was relatively busy at the time with both circuit and departing traffic. Examination of the Air Traffic Services communications tape in the period leading to the accident showed that the Tower Controller asked the pilot how many more circuits he intended to fly. The instructor responded that the next circuit would be his last and that it would be a "fully feathered full stop" (This phrase was indistinct and could not be understood from the tape until it had been replayed a number of times). During the final circuit, the instructor reported mid-downwind, adding "just confirming (.......) feathered landing" The Tower Controller asked the pilot to repeat the message, to which the response was "we just have one feathered" Again the phrase was difficult to understand and the reply by the Tower Controller referred to the previously crowded circuit. This out of context response was not queried by the instructor. On final approach with the pilot-under-instruction flying the aircraft, the right propeller feathered, and approaching the briefed committal height of 400 feet, a preceding aircraft was observed to be still on the runway. The approach was continued and full flap selected as both pilots thought that the other aircraft would clear the runway for their landing. At a height of about 300 feet, however, the Tower Controller instructed VH-UAU to go-around. The instructor took control of the aircraft and continued the approach, but the Tower Controller repeated the go-around instruction. The instructor then applied full power on the left engine and told the pilot under instruction to start the right engine. By this stage, the aircraft had descended to about 100 feet above ground level. It overflew the aircraft on the runway and continued a slow descent until it struck trees and spun into the ground about one kilometre beyond the end of the runway. No attempt was made to retract the landing gear and flaps. The instructor said that after hearing the first go-around instruction, he had intended to land beyond the aircraft on the runway but decided there was insufficient runway remaining for such a course of action. He then attempted to reach a clear area beyond the airfield boundary, but the aircraft struck the trees prior to this. The investigation established that the Tower Controller was not aware that VH-UAU had one propeller feathered until the stationary propeller was sighted after the second go-around instruction was given. Because the advice from the instructor concerning the feathered propeller was transmitted as an "add-on" to standard radio phraseology, there was no direct means of him knowing whether or not his intentions had been understood by the Tower Controller.

Significant Factors:

The following factors were considered relevant to the development of the accident:

1. Radio transmissions from the aircraft were of poor quality.

2. The Tower Controller was not aware that the aircraft was operating with one propeller feathered.

3. The approach was continued below the briefed committal height without a landing clearance having been issued and with the runway occupied by another aircraft.

4. An attempt was made to restart the right engine, however, no attempt was made to retract the landing gear and flaps.

Recommendations:

There is no operational difference between flying with one engine shut down for training purposes and a genuine engine failure. In the latter case, the aircraft is given priority in the landing sequence by air traffic control. There is justification, therefore, for some formal procedure whereby the practice of shutting down an engine in the circuit for training purposes is conditional upon a separate clearance from the tower controller. The recommendation is made that the Civil Aviation Authority give consideration to amending procedures to the effect that aircraft require a formal clearance for practice engine shutdown exercises in circuit traffic patterns.

Occurrence summary

Investigation number 199003059
Occurrence date 23/04/1990
Location 1 km west of Archerfield
State Queensland
Report release date 11/09/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Beech Aircraft Corp
Model 95
Registration VH-UAU
Serial number TD-380
Sector Piston
Operation type Flying Training
Departure point Archerfield QLD
Destination Archerfield QLD
Damage Substantial