Piper PA-31, VH-DER, Marble Bar, Western Australia, on 30 September 1990

Summary

Circumstances:

The aircraft entered the circuit, on the crosswind leg, for a normal approach and landing. The downwind checks were started abeam the upwind end of the airstrip with the pilot referring to a printed roller style check list. The first check, flaps selected to first stage, was carried out normally. Although the pilot lowered full flap during the approach, no other checklist items were completed. The aircraft landed with the landing gear retracted. The investigation indicated that the prime factors leading to this accident were pilot fatigue and channelised attention. The pilot's sleeping patterns had been disrupted during the five days preceding the accident because of health problems with his children. He was awoken five to six times each night and the pilot's longest period of rest, during the evening prior to the accident, was three hours. The pilot reported that he was not aware that he might have been suffering from fatigue and he had not thought to draw his supervisor’s attention to his lack of regular sleep. On arrival over Marble Bar the pilot observed a 20-25 knot wind which required a landing on an airstrip he had only used once before. The pilot concentrated on his approach and landing, in the strong wind conditions, and it is likely that this coupled with fatigue led to his failure to complete his prelanding checks. A higher-than-normal power setting was used during the final approach, and the landing gear warning horn did not sound until the throttles were closed during the flare. Even when the horn sounded the pilot did not associate it with the landing gear position but instead wondered why the stall warning had sounded at such an early stage in the landing. The pilot advised that the landing gear warning horn was not sufficiently distinctive and, as a result, it did not alert him to the approaching problem.

Significant Factors:

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

1. The pilot was probably suffering from sleep pattern related fatigue however he was not aware of this, nor did he think to draw his supervisor’s attention to a possible potential problem.

2. The pilot’s attention was channelled towards the approach and landing on an unfamiliar strip in strong wind conditions.

3. The distraction of the approach and the pilot's fatigue probably led to his failure to complete all the necessary check list items and the aircraft landed with the landing gear retracted.

4. The landing gear warning was not distinctive enough to warn the pilot of impending disaster. This accident was not the subject of an on-scene investigation.

Occurrence summary

Investigation number 199000102
Occurrence date 30/09/1990
Location Marble Bar
State Western Australia
Report release date 27/11/1990
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 Piper Aircraft Corp
Model PA-31
Registration VH-DER
Serial number 31-7912110
Sector Piston
Operation type Aerial Work
Departure point Port Hedland WA
Destination Marble Bar WA
Damage Substantial

Cessna 210, VH-TIU, "Wirribilla" 22 km North of Mt Sandon NSW, 18 October 1989

Summary

In the circuit area while making an approach for landing the pilot allowed himself to become distracted by the dry conditions of his property and did not complete the prelanding checks or extend the landing gear. He did not hear the landing gear warning horn during the landing flare. After touching down the aircraft slid straight for 60 metres. The pilot was not injured and damage to the aircraft was confined to bent propeller blades and distorted lower fuselage structure. The landing gear warning system was found to be serviceable during a functional check of the system at the accident site. The reason why the landing gear warning horn was not heard by the pilot during the landing flare could not be determined. This accident was not the subject of a formal on-site investigation.

Occurrence summary

Investigation number 198900018
Occurrence date 18/10/1989
Location "Wirribilla" 22 km North of Mt Sandon
Report release date 07/11/1989
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 Cessna Aircraft Company
Model 210
Registration VH-TIU
Serial number 21062324
Operation type Private
Departure point Maitland NSW
Destination Wirribilla NSW
Damage Substantial

Piper PA-30, VH-WVL, Canberra Airport, Australian Capital Territory, on 7 July 1989

Summary

Circumstances:

The pilot had considerable rotary wing but limited fixed wing experience, was undergoing type endorsement training. He was carrying out touch and go landings under instruction on runway 30, with a wind of 300/12 gusting up to 22 knots. After completion of a touch and go, it is probable that the landing gear was raised inadvertently, and the aircraft settled back onto the runway. The right and left main landing gear push rods, the landing gear mounting brackets and the landing gear motor mounting brackets were damaged at that time and both propellers touched the runway surface. The instructor took control, the landing gear was selected up, however the gear in transit light remained on. A fly past the tower confirmed that the right landing gear was hanging at about 45 degrees. While performing the emergency lowering procedures, it was noted that the landing gear motor circuit breaker had popped. The mirror showed the nose gear locked down, but a green light could not be obtained. An approach and landing was then made on the grass parallel with runway 30. Both main landing gear collapsed on touch down although the nose gear remained down and locked. The aircraft skidded for about 250 metres and stopped upright.

Significant Factors:

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

1. The pilot was inexperienced on fixed wing aircraft.

2. Inadequate supervision by the instructor.

3. The landing gear was retracted early.

4. Gusting wind conditions resulted in the aircraft settling back onto the runway.

Occurrence summary

Investigation number 198900012
Occurrence date 07/07/1989
Location Canberra Airport
State Australian Capital Territory
Report release date 16/08/1990
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 Piper Aircraft Corp
Model PA-30
Registration VH-WVL
Serial number 30-1986
Sector Piston
Operation type Flying Training
Departure point Canberra ACT
Destination Canberra ACT
Damage Substantial

Bell 206 B, VH-TFH, 170 km SE of Tindal NT, 13 September 1988

Summary

The pilot was engaged in a stream sampling operation. He reported that he was flying at an airspeed of about 20 knots at about 100 feet above the ground when sudden sink was encountered. Power was increased and the descent was arrested, but the main rotor blades struck a dead branch protruding from a tree. The low rotor rpm warning sounded, and the pilot reduced the power and autorotated to a clear area for a safe touchdown. The sink had been experienced in gusty crosswind conditions, while the pilot had been operating at a relatively low power setting. Post flight inspection revealed that the tail rotor had also received damage, probably caused by debris from the branch struck by the main rotor blades.

Occurrence summary

Investigation number 198800731
Occurrence date 13/09/1988
Location 170 km SE of Tindal
Report release date 06/05/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Bell Helicopter Co
Model 206
Registration VH-TFH
Serial number 1746
Sector Helicopter
Operation type Aerial Work
Departure point Hodgson River Station NT
Destination Hodgson River Station NT
Damage Substantial

Cessna 182, VH-DGG, Murgoo Homestead (230km NE Geraldton) WA, 18 September 1988

Summary

The aircraft had arrived at it's destination and was on final approach when it was subjected to the effects of a downdraught, followed by an updraught. The pilot elected not to overshoot from the approach but attempted to regain the normal glide path by using varying power applications. Wind considerations required that the approach be made into the setting sun and as the windscreen was covered with oil from a leaking oil cooler, the pilot's forward visibility was significantly reduced. This resulted in the aircraft touching down well into the strip. When the brakes were applied, there was no response from the right brake. The pilot was able to avoid some trees in his path but he was unable to avoid ruts on the road at the end of the strip. Had the aircraft touched down at the approach end of the strip it is likely that the pilot would have been able to stop the aircraft, within the confines of the strip, with the limited braking that was available. Had the brakes operated normally the pilot should have been able to stop, within the confines of the strip, even though the aircraft touched down well into the strip. This accident was not the subject of an on-scene investigation.

Occurrence summary

Investigation number 198800132
Occurrence date 18/09/1988
Location Murgoo Homestead (230km NE Geraldton)
Report release date 13/03/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway excursion
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 182
Registration VH-DGG
Serial number 182-55756
Operation type Business
Departure point Tardie Station WA
Destination Murgoo Homestead WA
Damage Substantial

Cessna 188, VH-RBX, Wallaroi (5 km SE Goondiwindi) NSW, 7 May 1988

Summary

The pilot was very experienced, having been an agricultural pilot for a considerable number of years. He had been aerial spraying a paddock for weed prevention with a herbicide, flying in a south to north direction, and passing under power lines which crossed the paddock from east to west.

The aircraft was observed to strike the power lines with the tip of its fin, causing the empennage to separate from the fuselage. The aircraft then dived into the ground approximately 50 metres beyond the power lines, bounced back into the air and slid for another 47 metres with the engine, propeller and right hand fuel tank separating from the aircraft. The fuel tank exploded and set fire to the grass on the steep slope of a creek bed, next to where the aircraft came to rest. The pilot received minor injuries as a result of the impact, but was able to remove himself from the aircraft without help. He then slipped on the steep angled wing-walk and fell into the fire, receiving severe burns to the areas of arms and legs not covered by clothing. There was no medical evidence indicating that the pilot had been effected by the herbicide before the accident. This type of aircraft has been the subject of many wire strikes to the fin, as it is higher than the propeller arc in level flight, and pilots can misjudge its position.

This occurrence was not the subject of an on-site investigation.

Occurrence summary

Investigation number 198802364
Occurrence date 07/05/1988
Location Wallaroi (5 km SE Goondiwindi)
Report release date 31/08/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wirestrike
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Cessna Aircraft Company
Model 188
Registration VH-RBX
Serial number 188-0123
Operation type Aerial Work
Departure point Wallaroi NSW
Destination Wallaroi NSW
Damage Destroyed

Cessna 152, VH-NAK, Moorabbin Airport VIC, 6 October 1989

Summary

On return to Moorabbin from the training area the pilot attempted two crosswind touch-and-go landings on Runway 31 right using 20 degrees of flap and normal approach speeds. The first was successful. On the second approach the aircraft touched down well into the runway and he had difficulty keeping the aircraft straight during the landing roll. After a ground roll of about 250 metres the pilot decided to make the landing a full stop because he thought that there was insufficient runway remaining for a touch-and-go. In reality there was still about 600 metres of runway available for a go-around. As the aircraft slowed down the pilot had increasing difficulty keeping the aircraft straight. With the wind of 250 degrees gusting from 12 to 19 knots, the aircraft veered left. He decided to try to bring the aircraft to a controlled stop on the grass with the intention of taxiing back on to the runway. A short distance after leaving the sealed runway the nosewheel sank in soft damp ground and the aircraft slowly tipped up on to its right wing tip before settling back on to its wheels. During his previous training the pilot had completed one lesson in crosswind landings with an instructor. However the gusty crosswind conditions on the day of the accident were more severe than he had encountered before and he was unaware that the grass surface was soft. This accident was not the subject of a formal on scene investigation.

Occurrence summary

Investigation number 198901555
Occurrence date 06/10/1989
Location Moorabbin Airport
Report release date 27/10/1989
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 None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 152
Registration VH-NAK
Serial number 1585027
Operation type Flying Training
Departure point Moorabbin Airport VIC
Destination Moorabbin Airport VIC
Damage Substantial

Gyrocopter, Not Reg, Redwood, 20 km north-east of Traralgon, Victoria, on 10 July 1990

Summary

Circumstances:

The pilot completed some dual flying earlier in the morning in another pilot's gyrocopter. About 10 hours dual flying had been completed with this other pilot over recent weeks. He then decided to make a solo flight in his own single place gyrocopter. The intention was to fly eight to ten circuits and low passes along the airstrip to get the feel of the aircraft. The first circuit appeared to proceed smoothly at an altitude of about 250 feet above the ground until the turn onto final approach. When that turn was started the aircraft assumed a reasonably steep nose down attitude. Engine noise remained constant until the aircraft hit the ground tracking about 15 degrees to the left of the landing direction. A detailed wreckage inspection did not reveal any pre-existing defect that may have contributed to the accident.

Significant Factors:

The following factor was considered relevant to the development of the accident:

1. The investigation did not determine why the aircraft hit the ground in the manner that it did.

Occurrence summary

Investigation number 199001178
Occurrence date 10/07/1990
Location Redwood, 20 km north-east of Traralgon
State Victoria
Report release date 15/02/1991
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Eurocopter
Registration Not registered
Sector Helicopter
Operation type Private
Departure point "Redwood" VIC
Destination "Redwood" VIC
Damage Destroyed

Cessna 501, VH-LCL, Lord Howe Island, New South Wales, on 22 April 1990

Summary

Circumstances:

The aircraft was being used for a pleasure flight for the owner and some friends. The Captain calculated the landing distances required for both runway 28 and 10, based on weather reports obtained at briefing, which indicated a strong northerly wind component. An updated report received some 30 minutes before descent confirmed the wind as 290 degrees at 7 knots. Approaching the island and becoming visual, the crew noted the windsock near the western end of the runway to be indicating a slight headwind component in the 10 direction and decided on a straight in approach to runway 10, to avoid an approaching squall/shower. The aircraft touched down firmly a short distance beyond the threshold. Speed brakes were immediately extended and wheel braking applied. About four seconds later the Captain called for the drag chute to be deployed. Although the co-pilot correctly activated the handle, it became obvious that the chute had not deployed as no increase in retardation occurred. When the Captain realised that the aircraft could not be stopped on the runway remaining, he attempted to turn the aircraft towards a clear grass area to the right. However, the aircraft was aquaplaning on the wet surface and did not respond to steering inputs for some distance. The aircraft left the bitumen tracking to the right. It collided with a gable marker, passed through a fence, continued down an embankment, across a road, through a second fence and came to rest approximately 90 metres from the runway end and 70 metres to the right of the extended centreline. The left main and nose gear legs were torn off. Witnesses to the accident said that when the aircraft landed, the runway was very wet, and the wind was westerly at 5 to 10 knots. It was determined that the Captain had made some miscalculations in his pre-flight assessments. He had noted the landing distance available as being the same for both runways, whereas runway 28 has a reduced length due to terrain clearance requirements on the approach. Under the conditions both forecast and prevailing, and using the criteria applicable at the time for an aircraft fitted with an alternate means of retardation, i.e. drag chute, the landing distances required for both runways were greater than the landing distances available. The Captain had also evidently applied incorrect techniques during the landing. He had not attempted to deploy the drag chute immediately the nosewheel was on the ground and had not applied unmodulated pressure to the anti-skid braking system. These measures are required by the manufacturer to obtain maximum performance. It was found that the drag chute canister lid had been sealed with tank sealant and painted over. The latch assembly had operated but the drogue chute spring was insufficiently strong to break the seal. When the sealant was prised away from around the lid, the system operated normally. This error had not been found during a check of the aircraft immediately following repainting. The lid had the appearance of an oblong radio antenna and was not marked in any distinguishing manner. The problem should also have been noticed during a subsequent inspection of the drag chute for moisture. The inspection is required every 90 days if the drag chute has not been deployed and requires the removal of the lid and drogue chute in order to feel the main chute for moisture. The condition of the sealant would indicate that this had not been carried out.

Significant Factors:

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

1. Inadequate pre-flight planning and preparation by the flight crew. The runway distance required was in excess of the distance available on either runway.

2. Adverse runway and weather conditions - wet surface and downwind component.

3. Improper sealing of drag chute canister.

4. Inadequate maintenance of the drag chute system. 5. Improper operation of wheel brakes.

Recommendations:

1. It is recommended that where a drag chute is fitted, the Civil Aviation Authority considers requiring some type of appropriate marking be applied to the canister lid to clearly identify its purpose.

Occurrence summary

Investigation number 199001981
Occurrence date 22/04/1990
Location Lord Howe Island
State New South Wales
Report release date 10/09/1990
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 Cessna Aircraft Company
Model 501
Registration VH-LCL
Serial number 501-0145
Sector Jet
Operation type Private
Departure point Sydney NSW
Destination Lord Howe Island NSW
Damage Substantial

Bell 47 G2, VH-UTU, Moonstone (56km NE Alpha) QLD, 19 June 1989

Summary

The pilot reported that the first flight of the day commenced at 0700 hours and landed to refuel after one hour and forty five minutes. She stated that before refuelling, she dipped the tank and noted that there was 15 to 20 litres of fuel remaining. The next flight commenced at 0900 hours, and at 1040 hours the helicopter departed the muster area to return to the refuelling point, which was about five minutes away. About two minutes later, the engine coughed once and then stopped. The aircraft was autorotated onto a cleared track, and during the landing the mainrotor struck the tailboom and the skids were bent. Inspection of the wreckage revealed that the fuel supply had been exhausted. This occurrence was not the subject of an on-site investigation and the above information was provided by the pilot and passenger.

Occurrence summary

Investigation number 198903783
Occurrence date 19/06/1989
Location Moonstone (56km NE Alpha)
Report release date 24/08/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Bell Helicopter Co
Model 47
Registration VH-UTU
Serial number 20
Sector Helicopter
Operation type Private
Departure point Moonstone QLD
Destination Moonstone QLD
Damage Substantial