Collision with terrain involving Cessna C152, VH-BUO, 3 km east of Kerswell Point, Lake Burragorang, New South Wales, on 21 December 1990

Summary

Circumstances:

The daily flying program authorised the instructor to fly with the student for a period of general flying revision in the training area. Prior to boarding VH-BUO the instructor discussed with the instructor from another Cessna aircraft, VH-HCE, his intention to proceed on a scenic flight to Lake Burragorang. The specific intention was to view an old telephone box located on an island of Kerswell Point. As the instructor from VH-HCE had not flown in this area it was agreed that both aircraft would proceed in company, with VH-BUO leading. Approaching Lake Burragorang, both instructors established radio communications on a VHF discrete frequency. When in the vicinity of the western extremity of the lake both aircraft descended and turned to take up a generally easterly track over the water. It was reported the aircraft levelled at a height of approximately 500 feet above water level. Approaching Kerswell Point from the west, VH-HCE gradually closed on VH-BUO. When the aircraft were about one kilometre east of Kerswell Point, VH-HCE passed to the right of VH-BUO with a lateral separation of 100 to 200 metres. The crew then lost sight of VH-BUO which appeared to be in a shallow climb and about 100 feet higher than VH-HCE. The instructor in VH-HCE attempted to call VH-BUO on the discrete frequency, but there was no response. There was no further contact with VH-BUO. Concerned by the sudden loss of contact, the instructor of VH-HCE turned back towards Kerswell Point. When there were no sighting of the Cessna and no radio contact, he set heading for Camden. However, about 10 kilometres from Camden, he again returned to the Kerswell Point area for another unsuccessful search. Upon returing to Camden the instructor reported that VH-BUO was overdue. A search was begun later in the afternoon but it was not until the following day that wreckage from the Cessna was found on the shoreline south of Kerswell Point. The aircraft was eventually located on the lake bed by sonar in 47 metres of water, approximately 3 kilometres east of Kerswell Point. The wreckage was subsequently recovered and an examination revealed the aircraft had collided with the water at a speed of about 100 knots, consistent with the aircraft being in a shallow descent and moderately banked to the left at the time of impact. No evidence was found to indicate the aircraft was other than airworthy immediately prior to the accident. Weather conditions over Lake Burragorang at the time of the accident were reported to be fine and clear with an easterly breeze of 5 to 10 knots, and scattered cloud at 3500 feet. The events which occurred immediately before the collision with the water, were not positively determined. However, the circumstances of the accident are consistent with the aircraft being operated at a very low height. During the course of the investigation, evidence was obtained concerning the conduct of operations by the training organisation which reflected adversely upon the level of supervision. These matters were bought to the attention of the appropriate authorities for separate investigation.

Significant Factors:

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

1. Unauthorised low flying in an environment conducive to visual illusions.

2. Inadequate level of supervision exercised over the conduct of flying training operations.

Occurrence summary

Investigation number 199002035
Occurrence date 21/12/1990
Location 3 km east of Kerswell Point, Lake Burragorang
State New South Wales
Report release date 24/12/1991
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 Cessna Aircraft Company
Model 152
Registration VH-BUO
Serial number 15283507
Sector Piston
Operation type Flying Training
Departure point Camden NSW
Destination Camden NSW
Damage Destroyed

Bell 47J-2A, VH-INW, Aboard Ship "Chita Maru", (13km NW Port Hedland WA), 21 August 1972

Summary

The ore carrier had departed from Port Hedland and was making about 10 knots in fine conditions and a slight sea swell. Arrangements had been made for the helicopter to fly from Port Hedland to pick up the marine pilot on-board the ship when it was about 8 miles off-shore. The on-board landing site selected for landing the helicopter was the starboard side of No 8 hatch cover, which had the letter H painted on it. The complete hatch cover was divided along the centreline of the ship by 6 pairs of walkway stanchions which could be positioned upright or lie flat, pointing outwards athwart the hatch cover. These stanchions were horizontal at the time of the accident but some had their ends sloped upwards. The approach was made to the No 8 hatch cover from the starboard side of the ship and resulted in a normal landing on the starboard side of that cover. After the marine pilot boarded the helicopter, it was brought into the hover and as it did so, it slid slightly forward on its floats towards the stanchions. When the helicopter pilot applied power and attempted to climb away, the aircraft tilted forward violently and the rotor blades struck the hatch cover. The helicopter came to rest on the port side of the hatch cover in an upright position. The helicopter was equipped with rubber floats, the lower portions of which were covered by loose fitting canvas soles to reduce wear on the floats. When the helicopter slid forward during the attempted take-off, one of the stanchions caught in the canvas sole of the starboard float without the knowledge of the helicopter pilot.

Occurrence summary

Investigation number 197204951
Occurrence date 21/08/1972
Location Aboard Ship "Chita Maru", (13km NW Port Hedland WA)
Report release date 01/10/1987
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-INW
Serial number N/K
Sector Helicopter
Operation type Charter
Departure point N/A
Destination Port Hedland Harbour
Damage Destroyed

Cessna 340A, VH-XGL, 17 km east of Ceduna, South Australia, on 24 January 1991

Summary

Circumstances:

The aircraft was refuelled by the pilot immediately prior to the accident flight. It was reportedly the first occasion on which he was able to fill the tanks to capacity due to weight considerations on previous legs. The pilot also conducted tyre inflation checks during which he confirmed that no drain cocks were left open after the water drain checks. Some 20 kilometres short of his destination, the engines malfunctioned which lead to a total loss of power from what the pilot believed to be complete fuel exhaustion. A MAYDAY call was made and the pilot reported descending through cloud and then sea mist. Fortunately, as the pilot regained visibility, he noticed a whitish track in the beam of the landing lights, and he was able to manoeuvre and select the landing gear down in the remaining height available. The landing gear did not have time to extend fully before the aircraft touched down on the dirt road. The aircraft slid some 50-60 metres on its under-surface before the left wing struck some roadside scrub which slewed the aircraft through about 150 degrees as it came to rest. The pilot had flight planned to allow the mandatory fuel reserves and was puzzled as to how the aircraft could have run out of fuel. The investigation was confined to this aspect of the operations as there were no reported aircraft anomalies. In examining the pilot's fuel management procedures, two anomalies were discovered. Contrary to the aircraft operating manual, he had run the aircraft engines on the main tanks for 90 minutes after engine start rather than 90 minutes after take-off. This practice would result in the main tanks containing more fuel than recommended when the subsequent selection of the auxiliary tanks is made. When the auxiliary tanks are selected, the fuel is fed directly to the engines. However, the fuel from the auxiliary tanks that is not used by the engines is pumped back into the main tanks. With the main tanks containing more fuel than is recommended and continually being topped up by the engine fuel return pumps, the main tanks will eventually fill up and start to overflow, thereby reducing the aircraft's overall endurance. The other anomaly related to the pilot's report that fuel transfer from the only nacelle tank to the main tanks was indicated as complete after some 34 minutes rather than nearly 60 minutes as reported in the operating manual. This anomaly would indicate that there was more fuel in the main tanks than recommended. The significance of this difference was not noted by the pilot. A witness reported that some 13 litres of fuel remained in the nacelle tank after the crash and other evidence suggested spillage during the crash. Notwithstanding, the amount of fuel lost from the nacelle tank and possible venting would not account for the magnitude of the fuel shortage experienced by the pilot. The aircraft had only been available for operations for a short time and the operator had reportedly not been aware of any fuel usage rates different from the manufacturer's recommended figures and they recommended the use of these rates to the pilot. The pilot stated that he was extremely attentive to fuel considerations and usually calibrated his own aircraft dipsticks, but he had not had time to do so for this aircraft. In addition, due to time constraints and fuel loads, he had not been able to establish an actual fuel usage rate. After the accident, evidence from other operators of the aircraft type suggested that a fuel planning figure as high as 240 pounds/hour should be used compared to the manufacturer's recommended figure of 182 pounds/hour. To compound the problems for the pilot, he had established that there was a significant error in the aircraft fuel gauges. Evidence points to the fact that the pilot was very meticulous in his approach to flight planning and operating procedures although he had only a limited experience on the aircraft type. Other evidence available to the investigation suggests, however, that the pilot was not as confident in his knowledge of aircraft systems and operations as he would like others to believe. Albeit in hindsight, the accident might have been avoided if the pilot had not placed implicit faith in his preflight fuel calculations and had had a more healthy scepticism over Whyalla at which point he had done a recalculation of his fuel reserves. A better knowledge of the aircraft's fuel system should have caused him to be more circumspect about his actual fuel remaining as evidenced by the nacelle fuel tank transfer anomaly. In addition, prudence should have engendered further caution in what was his first long range operation in a relatively unfamiliar aircraft for which he had no established fuel usage rates.

Significant Factors:

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

1. The pilot was inexperienced on the long-range operation of the aircraft.

2. Accurate fuel usage rates were not available to the pilot.

3. Inaccurate calculations of fuel usage and/or fuel loss or mismanagement led to fuel starvation of the engines. This accident was not the subject of an on-scene investigation.

Occurrence summary

Investigation number 199100512
Occurrence date 24/01/1991
Location 17 km east of Ceduna
State South Australia
Report release date 04/06/1991
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 340
Registration VH-XGL
Serial number 340A-0739
Sector Piston
Operation type Private
Departure point Parkes NSW
Destination Ceduna SA
Damage Substantial

Hughes 269A, VH-HRR, Mt Florance - 150km South East Karratha WA, 25 November 1988

Summary

The pilot had been mustering for 2.5 hours. He then landed to refuel the aircraft and collect the passengers. As the pilot subsequently attempted to climb the aircraft, out of ground effect, he noticed the rotor and engine rpm had decayed. The pilot attempted a run-on landing, however, the aircraft landed heavily, the main rotor struck the tail boom and the tail shaft was severed. The pilot did not report any engine or aircraft system defect which might have contributed to the accident. He had relatively limited experience on the aircraft type and in the type of operation being conducted. The pilot's description of a decay in rotor rpm accompanied by a decay in engine rpm indicates overpitching of the main rotor. The pilot's general experience coupled with the hot/heavy/high and relatively confined circumstances of this take-off would have contributed to his attempting to introduce more collective pitch than the power available was able to support. This accident was not the subject of an on-site investigation.

Occurrence summary

Investigation number 198800142
Occurrence date 25/11/1988
Location Mt Florance - 150km South East Karratha
Report release date 16/03/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Hard landing
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Hughes Helicopters
Model 269
Registration VH-HRR
Serial number 630240
Sector Helicopter
Operation type Private
Departure point Mt Florance WA
Destination Mt Florance WA
Damage Substantial

Collision with terrain involving Piper PA32R, VH-RFW, 26 km north-east of Kempsey, New South Wales, on 11 October 1990

Summary

Circumstances:

The aircraft had flown from Bendigo to Mudgee where it was refuelled. After leaving Mudgee the pilot diverted from his planned route due to weather and tracked via Muswellbrook, Maitland, Gloucester, and Taree. At 1626 hours the pilot reported at Port Macquarie at 5 000 ft and requested airways clearance. The aircraft was cleared to track coastal to Coffs Harbour and to enter the control area at 4 500 ft. The pilot's acknowledgement of this clearance was the last recorded transmission from the aircraft. The estimated entry time for the control area (at 25 nm from Coffs Harbour) was 1642 hours. At 1645 Coffs Harbour Flight Information Service attempted to contact the aircraft for traffic purposes, but there was no reply. At 1807 hours a search aircraft reported an Emergency Locator Beacon signal on 121.5 MHz in the South West Rocks area. However, due to the inaccessible nature of the terrain, and mist after dark, the wreckage was not found until 0330 on the following morning. The accident site was in the Hat Head National Park, about 38 nm from Coffs Harbour, and about 4 nm east of the direct Port Macquarie to Coffs Harbour track. The aircraft had struck trees, in a wings level attitude, at a descent angle of 16 degrees to the horizontal, on a track of 021 degrees. Although subsequently destroyed, the aircraft had been intact at initial impact. Witnesses reported that a severe electrical storm with hail had passed through the area between Kempsey and South West Rocks between 1630 and 1700 hours. Based on estimated time intervals and known groundspeeds, it was considered that the accident occurred at about 1638-1640 hours. A Bureau of Meteorology analysis indicated that at this time the severe thunderstorm would have been almost over the accident site. Severe updraughts and downdraughts are known to occur in the vicinity of such large storms and the magnitude of such downdraughts could exceed the climb capability of a light aircraft.

Significant Factors:

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

1. The pilot continued VFR flight into adverse conditions.

2. Weather conditions were extreme with a severe thunderstorm.

3. The pilot encountered circumstances beyond his control and was unable to prevent the aircraft descending into the ground.

Occurrence summary

Investigation number 199002011
Occurrence date 11/10/1990
Location 26 km north-east of Kempsey
State New South Wales
Report release date 05/12/1991
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 Piper Aircraft Corp
Model PA-32
Registration VH-RFW
Serial number 32R-7780164
Sector Piston
Operation type Private
Departure point Mudgee NSW
Destination Coffs Harbour NSW
Damage Destroyed

Cessna R182, VH-JMS, Yulara NT, 11 August 1989

Summary

The pilot made a normal approach to land on Runway 13 with two stages of flap but at a higher than normal airspeed of about 75 knots. He recalled that the flare for landing was good but the aircraft "didn't want to sit down" even with the power off. He reported that as soon as the aircraft touched down it veered to the right and he was unable to control it with the use of rudder but he did not use the brakes. The pilot had assessed the wind for landing as being a slight crosswind from the left. As the aircraft left the runway, the pilot re-applied the power and the aircraft apparently did not climb away as expected but drifted to the right. The pilot then closed the throttle and was aware of the aircraft going up on one wheel but he was not aware of the aircraft hitting both wingtips on the ground as it slewed around and sheared off the gear. Two Civil Aviation Authority Examiners of Airmen who witnessed the accident reported that the wind at the time of the accident was 110 degrees 10-15 knots gusting 20-25 knots. Consideration of the circumstances points to the pilot having induced a wheelbarrow effect in an attempt to pin the aircraft on the runway for landing followed by the effect of a strong crosswind as the pilot attempted to go around from a loss of control situation. This accident was not the subject of a formal on scene investigation.

Occurrence summary

Investigation number 198900819
Occurrence date 11/08/1989
Location Yulara
Report release date 07/11/1989
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 182
Registration VH-JMS
Serial number R18201788
Operation type Private
Departure point Alice Springs NT
Destination Alice Springs NT
Damage Substantial

Hughes 269C, VH-KKJ, 2 km south of Alice Springs, Northern Territory, on 1 August 1989

Summary

Circumstances:

The pilot-in-command was carrying out flying training for the purpose of endorsing another commercial pilot on the aircraft type. He was demonstrating tail rotor emergency procedures by simulating a tail rotor failure using right pedal, with the intention of making an approach and run-on landing into a cleared area. He was not happy with the approach so went around and repeated the exercise. He again set the aircraft into the simulated tail rotor failure configuration and continued the approach using about twenty degrees of left drift to maintain direction. At approximately ten feet above ground level, he reduced power and slowed the aircraft for the run-on landing. The aircraft, which was still drifting to the left, experienced a rapid sink rate and contacted the ground with its skids. It then rolled to the left and cartwheeled around its nose before coming to rest lying on its right hand side, facing back along the approach path. 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 simulated a tail rotor failure using right pedal, which was counteracted for with left drift.
  2. The aircraft suffered rapid sink when the power was reduced for landing.
  3. The aircraft was still drifting to the left at touch down.

Occurrence summary

Investigation number 198900817
Occurrence date 01/08/1989
Location 2 km south of Alice Springs
State Northern Territory
Report release date 15/01/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Hard landing
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Hughes Helicopters
Model 269
Registration VH-KKJ
Serial number 800952
Sector Helicopter
Operation type Flying Training
Departure point Alice Springs NT
Destination Alice Springs NT
Damage Substantial

Cessna 172N, VH-EIH, 20 km north-east Booligal, New South Wales, on 19 July 1989

Summary

Circumstances:

The pilot of the Cessna was operating in conjunction with an agricultural aircraft. As the latter aircraft was making an approach to land, the Cessna pilot indicated that he would make an inspection of a nearby strip. The agricultural pilot observed the Cessna making a low pass over the second strip, with the wing flaps selected up. He lost sight of the Cessna as he concentrated on his own landing. The Cessna was subsequently found to have collided with the ground in a left hand turn with 45 degrees of bank, with almost no forward speed and a higher-than-normal rate of descent. The flaps were retracted, and the engine was rotating at high rpm at the time of impact. The wreckage was located 50 metres to the left of the centreline and in line with the DEPARTURE end of the strip that the pilot was inspecting. The investigation did not disclose any defects with the aircraft that may have contributed to the accident. The investigation found that the aircraft was in a fully stalled condition at the time of collision with the ground. It appeared that the pilot made a low flapless inspection pass along the wet flight stip. At the end of the pass with full power he pulled up and entered a left hand turn. During the entry to the turn the aircraft stalled and there was insufficient height to complete a recovery. The factors which caused the pilot to lose control of the aircraft could not be positively determined. However, investigations of accidents that have occurred under similar circumstances, indicate that overconcentration on some aspect of the flight, e.g. the flight strip inspection or distraction by something outside the aircraft can result in a pilot paying insufficient attention to the operation of the aircraft. This in turn can lead to a loss of control at low level, often with insufficient time and height available for the pilot to recover before the aircraft collides with the ground.

Significant Factors:

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

1. The pilot probably allowed his attention to be diverted from the operation of his aircraft.

2. The pilot did not maintain sufficient airspeed for safe flight.

3. There was insufficient height available to complete a recovery from a stalled condition.

Occurrence summary

Investigation number 198900240
Occurrence date 19/07/1989
Location 20 km north-east Booligal
State New South Wales
Report release date 05/06/1990
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 Fatal

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172
Registration VH-EIH
Serial number 1727344
Sector Piston
Operation type Private
Departure point Natue NSW
Destination Natue NSW
Damage Destroyed

Neico Lancair 235, VH-HTD, Ballina Airport, New South Wales, on 23 December 1988

Summary

Circumstances:

The pilot was preparing to depart with a crosswind of about 15 knots from the right. At the time, the aircraft left wing fuel tank was about two thirds full, while the right tank was empty. The pilot performed a flapless take-off, rotating the aircraft at 50 knots, then climbed using a higher-than-normal nose attitude. Shortly afterwards the aircraft commenced to roll to the left, probably because of the low airspeed, and the lateral weight imbalance. The pilot attempted to raise the left wing by use of the aileron, but the aircraft stalled and struck the ground in a left wing low, 20 degree nose down attitude. The aircraft was still undergoing flight testing for type certification and its Certificate of Airworthiness. Data obtained from the test flight schedule indicated that the normal lift-off speed for this aircraft is 63 - 65 knots, with a 48-knot stalling speed in the zero-flap configuration. The pilot indicated that he had lifted the aircraft into the air at 50 knots on previous occasions, but this would have been done under more ideal conditions. The reason he attempted to take off below the recommended airspeed was on this occasion not determined. This accident was not the subject of an on-site investigation.

Significant Factors:

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

1. The pilot rotated the aircraft at a speed below the optimum take-off speed.

2. The pilot failed to maintain flying speed.

3. Loss of control with insufficient height available to effect a recovery.

Occurrence summary

Investigation number 198802415
Occurrence date 23/12/1988
Location Ballina Airport
State New South Wales
Report release date 23/03/1990
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 Neico Aviation Inc
Model Lancair 235
Registration VH-HTD
Serial number N149
Sector Piston
Operation type Aerial Work
Departure point Ballina NSW
Destination N/K
Damage Substantial

Cessna C188, VH-RYO, 20 km South of Wongan Hills WA, 27 July 1988

Summary

The pilot had completed a number of take-offs and landings from the one-way agricultural strip prior to the final flight. On each of the previous flights the pilot had turned right after take-off, climbed out and and carried out spreading operations over ground that fell away from the strip. On the final flight the pilot was to carry out spreading on a paddock to the left and uphill from the strip. The pilot inspected the rising ground and assessed that the aircraft's performance was sufficient to outclimb the rising ground with safety. The final take-off was normal until the pilot had reduced power, raised the flaps and commenced a slight left hand turn. At that point the pilot observed that the aircraft appeared to lose height, relative to the ground, and he considered dumping the load and landing the aircraft on the up slope. He rejected both of these options as he considered that obstructions caused by a fence and a powerline would make the situation worse. Before the pilot could take any further action the aircraft's mainwheels touched down, the aircraft bounced back into the air, collided with the fence and came to a stop in a recently ploughed and planted paddock, just short of the powerline. At the time of take-off, wind conditions may have created slight downdrafts. The gradient of the rising ground was about 7 percent. With optimum conditions (airspeed control, engine performance, etc.), at the prevailing density altitude and aircraft weight, the aircraft could have been expected to outclimb the rising ground. In this case the conditions were not optimum and the aircraft flew into the ground and fence.

Occurrence summary

Investigation number 198800129
Occurrence date 27/07/1988
Location 20 km South of Wongan Hills
Report release date 13/02/1989
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 None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 188
Registration VH-RYO
Serial number 18801353
Operation type Aerial Work
Departure point 20 km South of Wongan Hills WA
Destination 20 km South of Wongan Hills WA
Damage Substantial