Loss of control involving Cessna 150L, VH-IQB, 16 km south of Landor Station, Western Australia, on 4 June 1991

Summary

Circumstances:

The pilot was conducting mustering operations at low level at the time of the accident. Shortly after the aircraft made a low pass to indicate the position of some animals, it was observed descending at a steep angle. The aircraft commenced rolling to the right just prior to ground impact and was destroyed by a post-impact fire. All essential aircraft systems appeared capable of normal operation prior to the accident. There was no evidence that the pilot had suffered any pre-impact illness or sudden incapacitation. Although all of the precise factors leading to this accident could not be determined, the sequence of events is similar to many other accidents investigated by the Bureau, where the loss of control at low level following a low pass has been due to inattention to aircraft operations by the pilot. It was disclosed during the investigation that although the pilot had a valid mustering endorsement, he had not received any training in recovery from stall/spin conditions, typical of a loss of control in a Cessna 150, at low level.

Significant Factors:

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

1. It is probable that the pilot did not pay sufficient attention to the operation of the aircraft during low-level mustering operations.

2. The aircraft probably stalled and entered an incipient spin.

3. The loss of control occurred at too low an altitude for any recovery attempt to be successful.

Recommendations:

This type of loss of control is a factor in many of the low-level accidents investigated by the Bureau. Training and exposure in incipient loss of control situations, particularly in Cessna 150 type aircraft, is not included in all mustering and associated low flying endorsement programs. The Civil Aviation Authority in Western Australia advised all local pilots of the desirability of obtaining this type of training. It is recommended that the Civil Aviation Authority extend this advice to all pilots in Australia who have approval to conduct fixed wing operations at low level.

Occurrence summary

Investigation number 199100129
Occurrence date 04/06/1991
Location 16 km south of Landor Station
State Western Australia
Report release date 27/11/1991
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain, Loss of control
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Cessna Aircraft Company
Model 150
Registration VH-IQB
Serial number 15075374
Sector Piston
Operation type Aerial Work
Departure point Landor Station WA
Destination Landor Station WA
Damage Destroyed

Pterodactyl Ptraveller, 10-390, Fairlight Authorised Landing Area, 24 km south-west of Canberra, Australian Capital Territory, on 24 December 1989

Summary

Circumstances:

The pilot was to conduct solo training flights in a flying wing type ultralight aircraft. Directional control in this type of aircraft is achieved by yaw through the use of wing tip rudders. These rudders are spring loaded to the left and balanced by air loads in flight. During pre-flight assembly on the day of the accident, the control cable attachment to the left rudder was inadvertently positioned on the wrong side of a clamp near the wing tip rib. This allowed the cable, under some conditions to foul on the clamp. After assembling the aircraft, the pilot conducted some flights, until a heavy landing bent the main landing gear axle. The pilot used a steel pipe as a hammer to straighten the axle, but the shock loads from this operation dislodged the left hand wing tip rib and rear spar. Although an inspection was conducted, it did not discover the damage to the wing tip which would only have been apparent by removing the wing sail. On the subsequent flight at about 30 feet after take-off, the damaged left wing tip distorted due to aerodynamic loads, initiating an uncontrolled right roll. Attempts by the pilot to level the aircraft resulted in the incorrectly installed control cable attachment inducing further adverse distortion. The aircraft rolled to about 60 degrees, entered a rapid descent and clipped a parked aircraft before coming to rest in a nose down attitude. The engine which appeared to be operating normally was shut down by the pilot after the aircraft came to rest.

Significant Factors:

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

1. Incorrect assembly of the left hand rudder cable.

2. Shock load damage to the left hand wing tip structure during straightening of the landing gear axle.

3. Inadequate inspection of the aircraft for damage.

4. The damaged left hand wing tip distorted with increased aerodynamic loads. This accident was not the subject of an on-scene investigation.

Occurrence summary

Investigation number 198900025
Occurrence date 24/12/1989
Location Fairlight Authorised Landing Area, 24 km south-west of Canberra
State Australian Capital Territory
Report release date 17/08/1990
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 Serious

Aircraft details

Manufacturer Pterodactyl Ltd
Model Ptraveller
Registration 10-390
Serial number Unknown
Operation type Private
Departure point Fairlight ACT
Destination Fairlight ACT
Damage Substantial

Cessna C340, VH-FYG, Forrest WA, 21 April 1988

Summary

The pilot was attempting a normal night takeoff in light drizzle, with 7 to 10 knots of crosswind at the time of the accident. As the aircraft lifted off heavy rain started to fall. The aircraft appeared to accelerate normally to 120 knots. As the pilot completed the after takeoff checks he noted that the aircraft was descending at 200 feet per minute instead of climbing, although the nose of the aircraft was 10 degrees above the horizon. The pilot raised the nose still further and reduced the speed to 110 knots, however, this did not stop the aircraft from descending. At 510 feet indicated on the altimeter, the airfield elevation, the pilot levelled the aircraft and prepared for ground impact. The aircraft touched down, gear up, 3 km from the DEPARTURE end of the runway and slid to a stop in flat marshy country. The meteorological station at Forrest reported that during the aircraft's takeoff, the intensity of the rain increased and the surface wind swung around to give a 30 knot tailwind. During test flights prior to and after the accident the pilot-in-command was assessed as having slow cross reference skills and poor attitude control. It is possible that the pilot's performance contributed to the accident.

Occurrence summary

Investigation number 198800116
Occurrence date 21/04/1988
Location Forrest
Report release date 22/02/1989
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 340
Registration VH-FYG
Serial number 340-0215
Operation type Charter
Departure point Forrest WA
Destination Kalgoorlie WA
Damage Substantial

Cessna C182, VH-DBT, Corowa Aerodrome, New South Wales, on 26 May 1990

Summary

Circumstances:

The commencement of parachuting activity on the Corowa Drop Zone was delayed due to extensive cloud in the vicinity of the Corowa aerodrome. About mid- afternoon the cloud base had lifted sufficiently to permit descents from the minimum safe height. The aircraft took off carrying four parachutists. Their intention was to exit the aircraft for a "Hop and Pop" jump in which the main parachute deployment sequence is commenced immediately after leaving the aircraft. The four parachutists jumped at several second intervals, from a height of 2200 feet above ground level. Three parachutists main canopies opened normally, the fourth did not. The fourth parachutist, was observed to fall in a face down attitude until he struck the ground, fatally injured by the impact. During his fall, the pilot parachute from the main canopy system was seen to deploy and remain attached to the harness. There was apparently no attempt made by the parachutist, to initiate cut away action (to disconnect the main canopy from the harness) or deploy the reserve canopy. A specialist examination of the equipment revealed the line from the pilot parachute passed under the right leg strap preventing deployment of the main canopy. The reserve canopy and its deployment system were in a serviceable condition. The fatally injured parachutist was attempting his 42nd descent, held an "A" licence and was considered to be relatively inexperienced. He was using borrowed equipment which differed significantly from that on which he carried out the majority of his training. He had completed 39 descents with a harness/container system that incorporated a ripcord main canopy deployment and "single operation system" reserve canopy deployment. The borrowed equipment consisted of a throw away pilot chute main canopy deployment system, and a "two stage" reserve deployment arrangement. It was reported the parachutist was trained to use the borrowed equipment. The parachutist incorrectly fitted the borrowed equipment so that the right leg strap passed over the line from the pilot chute to the main canopy. Although the pins which secure the main canopy within the container were checked by another parachutist before the aircraft was boarded, the routing of the pilot chute line was not the subject of a deliberate check. (The reason why the parachutist did not deploy his reserve parachute was not determined). The descent was conducted from the minimum safe height above ground level and in the event of a complete failure of the main canopy to deploy, a rapid response was required to identify the nature of failure and deploy the reserve parachute. 

Significant Factors:

1. Parachutist lack of experience with this equipment.

2. The parachutist incorrectly donned the parachute equipment.

3. Prior to boarding the aircraft, a complete check of the parachutist’s equipment by an independent person, was not conducted.

4. The main canopy failed to deploy because the line from the pilot's chute passed under the right leg strap. 

Recommendations:

The following recommendations were made to the Australian Parachute Federation during the course of the investigation

1. All parachutists should have their complete equipment checked prior to boarding aircraft.

2. Inexperienced parachutists be discouraged from using borrowed equipment with unfamiliar operating systems.

Occurrence summary

Investigation number 199002047
Occurrence date 26/05/1990
Location Corowa Aerodrome
State New South Wales
Report release date 11/10/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Miscellaneous - Other
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Model C182
Registration VH-DBT
Serial number 18254061
Sector Piston
Operation type Private
Departure point Corowa NSW
Destination Corowa NSW
Damage Nil

Mooney M20J, VH-WCK, Rutherford, New South Wales, on 18 June 1989

Summary

Circumstances:

The pilot had recently been endorsed to fly, “Retractable Undercarriage" and "Constant Speed Propeller" aircraft and had accumulated six hours on this aircraft type. When the aircraft arrived in the circuit area the wind was westerly at 10-15 knots gusting to 20 knots. The pilot elected to conduct an approach to runway 23, although an into wind runway was available. The reason for this decision was not established. The pilot carried out a go-around from his initial approach. Following the second approach to the same runway the aircraft touched down heavily. Structural damage to the aircraft was sustained, with the left main landing gear door and retraction rod-end bearing being detached from the aircraft. After bouncing on the runway, the aircraft became airborne again, and with the landing gear down and hanging free, it was observed to commence another left hand circuit. At an estimated height of 200-300ft, the aircraft turned onto a low-level downwind leg with an increasing nose high attitude. The aircraft was then observed to roll into a spiral dive manoeuvre from which it failed to recover. The on-site investigation revealed that the aircraft had impacted soft waterlogged ground, outside the aerodrome boundary, in a near vertical attitude. Rear fuselage distortion was consistent with the aircraft having been rolling about the longitudinal axis at the time of impact. Ground impact had reduced the cockpit area to non-survivable dimensions. The engine and propeller, which were buried in the soft ground beneath the cockpit area, showed no evidence to indicate that the propeller had struck the ground during the heavy landing on the runway. Inspection of the aircraft failed to find any pre-existing defects or abnormalities which were contributory to this accident. Flight test evaluation of the stall characteristics of this model aircraft has indicated that it only marginally achieves the certification requirements and is difficult to control in all but ideal stall conditions. It is considered probable that the attention of the pilot was diverted from the operation of the aircraft due to the failure of the landing gear to retract and the cockpit workload and associated anxiety following the heavy landing. Medical evidence indicated that both occupants had been holding their respective control columns at the time of impact. What effect this may have had on the development of the accident was not established. The reason why the aircraft entered an abnormal flight manoeuvre at an altitude from which the pilot was unable to recover could not be determined.

Significant Factors:

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

1. The pilot elected to carry out an approach in gusty crosswind conditions when a more suitable runway was available.

2. The pilot did not maintain a stabilized approach to land, possibly because of the turbulent conditions and/or his lack of familiarity with the aircraft.

3. Heavy landing.

4. Following the heavy landing the pilot encountered unforeseen circumstances beyond his capability.

5. The pilot's attention was probably distracted from the operation of the aircraft.

6. Loss of control with insufficient height to effect a recovery.

7. Possible inadequate training on the specific aircraft type, particularly with regard to slow speed handling and stalling characteristics.

Recommendations:

1. That the Civil Aviation Authority consider removing this model aircraft from the group endorsement for single engine, retractable undercarriage, and constant speed aircraft in favour of a specific endorsement which requires additional flying training in stall and spin recovery techniques.

2. That the Civil Aviation Authority provide the industry with advisory information concerning stall warning strips and switches, their positioning, flight testing and procedures for setting and adjusting.

Occurrence summary

Investigation number 198900010
Occurrence date 18/06/1989
Location Rutherford
State New South Wales
Report release date 27/02/1990
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 Fatal

Aircraft details

Manufacturer Mooney Aircraft Corp
Model M20
Registration VH-WCK
Serial number 24-0830
Sector Piston
Operation type Private
Departure point Bankstown NSW
Destination Maitland NSW
Damage Destroyed

Hughes 269 A, VH-JMY, 55 km NE Bourke NSW, 16 December 1986

Summary

The pilot was mustering cattle towards a crush. The last animal was reluctant to enter the gate into the crush, and the pilot flew low and behind the animal to encourage it to move. The front of the left landing skid caught under the top wire of the adjacent fence. The aircraft pitched forward and struck the tubular steel crush before coming to rest on its side. Visibility was reduced by dust. The accident occurred during a period of high pilot workload and eleven and one half hours after the pilot had commenced work for the day.

Occurrence summary

Investigation number 198602363
Occurrence date 16/12/1986
Location 55 km NE Bourke
Report release date 11/03/1988
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Hughes Helicopters
Model 269
Registration VH-JMY
Sector Helicopter
Operation type Private
Departure point Corella Station NSW
Destination Corella Station NSW
Damage Destroyed

Piper 28-235, VH-CEE, Clermont QLD, 27 August 1987

Summary

The pilot and his passengers were on the final stages of a trip through central and northern Australia. After spending the night at Clermont they were observed to enter the aircraft, and following engine start an engine run-up was carried out. Witnesses reported that at times during the run-up the engine ran roughly. Following the run-up, the pilot taxiied the aircraft to the runway threshold and the takeoff was commenced. During the takeoff run the engine sound was reported as being normal. The aircraft was then observed to become airborne and a short time later the sound of an impact was heard. The wreckage was located in timbered country, 475 metres beyond the upwind end of the departure runway. The investigation revealed that the No 3 cylinder exhaust valve had stuck shortly after takeoff, resulting in a substantial loss of engine power. The valve appears to have become jammed in the closed position due to a build up of carbon in the valve guide which resulted in the pushrod bending. Following the power loss the pilot was faced with carrying out a forced landing on unsuitable terrain.

Occurrence summary

Investigation number 198703497
Occurrence date 27/08/1987
Location Clermont
Report release date 11/03/1988
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-28
Registration VH-CEE
Serial number 28-10679
Operation type Private
Departure point Clermont QLD
Destination Emerald QLD
Damage Destroyed

CESSNA 172 N, VH-BAC, Cox Bight TAS, 2 February 1987

Summary

Before commencing a fishing expedition, the pilot had determined that a particular section of beach was frequently used by light aircraft. An uneventful landing was made on the beach, and later the pilot made a take-off and circuit of the area before landing on another section of the same beach. The group had no success with their fishing, and the pilot decided to fly to another beach on the opposite side of the bight. During the landing roll, the pilot discovered that the left brake was not operating. The aircraft subsequently ran through a shallow water run, entered an area of soft sand, and overturned. The pilot had no previous experience in operations from beaches, and the operator of the aircraft was not aware that a beach landing was intended. The section selected was not used by other pilots who operated in the area. The reason for the brake failure was not determined, however the left brake unit had a recent history of malfunctions, possibly related to defective seals. This accident was not the subject of an on scene investigation.

Occurrence summary

Investigation number 198701424
Occurrence date 02/02/1987
Location Cox Bight
Report release date 11/03/1987
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 172
Registration VH-BAC
Operation type Private
Departure point Cox Bight TAS
Destination Cox Bight TAS
Damage Substantial

Cessna 182-H, VH-KMM, Ord River Homestead WA, 13 August 1985

Summary

The destination was served by two landing sites - an ALA near the homestead and a licenced strip 12 kilometres to the north. The pilot elected not to use either, but made an approach to a road adjacent to the homestead. The usable length of this road was 450 metres and the width was less than 3 metres. The approach was made over a shed in light downwind conditions. Touchdown occurred about 200 metres from the end of the road, and the pilot then attempted to go-around. During this attempt the aircraft struck three wire fences before colliding heavily with a tree. Fire broke out and gutted the wreckage. The reason the pilot elected to land on the road and not one of the available ALAs could not be determined, although it is possible his decision was influenced by one of his passengers. Once the pilot elected to go-around, it seems likely that he became concerned about avoiding a 10 metre high tree located directly ahead off the end of the road. Witness reports and wheel marks indicate that a slight left turn was made almost as soon as the aircraft lifted off, presumably to miss that tree. However, the left turn took the aircraft towards the line of fences which ran almost at right angles to the flight path, just off the road. These fences would have been difficult to see, and it is unlikely that the pilot was aware of their presence. Control of the aircraft was lost when it struck the fences.

Occurrence summary

Investigation number 198500143
Occurrence date 13/08/1985
Location Ord River Homestead
Report release date 10/03/1986
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Cessna Aircraft Company
Model 182
Registration VH-KMM
Operation type Business
Departure point Kununurra WA
Destination Ord River WA
Damage Destroyed

Cessna 172M, VH-MGZ, Mills Cross (6 km south of Bungendore), New South Wales, on 12 August 1989

Summary

Circumstances:

At the completion of a gliding turn, during a period of dual instruction, the engine failed to respond when the student re-opened the throttle. The instructor took control of the aircraft and attempted, unsuccessfully, to regain engine power by manipulation of the throttle. Leaving the engine idling, he selected a waterlogged paddock and commenced a flapless approach at approximately 60 knots. On short final it became apparent to the pilot that the aircraft was undershooting the paddock landing site. He selected 20 degrees of flap in an attempt to balloon the aircraft over a ditch and fence. The nosewheel touched the fence, and the aircraft landed heavily on the nose and left mainwheel, bounced, then skidded in the mud with the nosewheel sinking into the soft surface. This caused the aircraft to overturn. Both occupants were uninjured and evacuated the inverted aircraft without assistance. An inspection of the area surrounding the accident site indicated that a roadway parallel to the selected paddock would have afforded a better forced landing site. The pilot stated that he did not consider the roadway as he had been preconditioned or had pre-conditioned himself to carry out practice forced landings in paddocks. Examination of the engine revealed that the throttle control cable assembly outer flexible casing had separated from the staked joint of the rigid conduit at the carburettor attachment end. This prevented the inner cable from moving when the throttle was operated, therefore the carburettor throttle butterfly remained on the idle stop. The Aircraft Manufacturer's Service Manual specifies a requirement to inspect the staked joint of this throttle control cable assembly. The maintenance of this aircraft had been performed with reference to CAO 100.5.1, and no such specific inspection was called for in the schedule.

Significant Factors:

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

1. Failure of the throttle control cable assembly.

2. Failure of the pilot to select the best available landing site.

3. The Civil Aviation Authority maintenance inspection schedules do not reflect manufacturers specific inspection requirements.

Recommendations:

1. It is recommended that the Civil Aviation Authority review, and amend as necessary, CAO 100.5.1 Appendix 4 inspection schedules, to include a requirement for operators (who elect to maintain Aircraft, Engines and Equipment to these schedules) to comply with and observe, all of the Manufacturers Specific Inspections and Component Replacement Life Limits.

2. It is recommended that the Civil Aviation Authority, pending the review and consideration of the above item 1, notify all operators of Cessna 172, and similarly affected aircraft, of the specific throttle control check (detailed in the Cessna Service Manual) and initiate retrospective action to ensure compliance.

Occurrence summary

Investigation number 198900015
Occurrence date 12/08/1989
Location Mills Cross (6 km south of Bungendore)
State New South Wales
Report release date 23/04/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172
Registration VH-MGZ
Serial number 17266694
Sector Piston
Operation type Flying Training
Departure point Canberra ACT
Destination Canberra ACT
Damage Substantial