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

Cessna 182H, VH-PKJ, Mandurah WA, 11 May 1988

Summary

The pilot had limited experience on Cessna 182 aircraft. He planned to carry out some practice circuits at the local airfield. All of the pilot's recent flying had been completed at a licenced aerodrome with a sealed runway. The local airfield consisted of a grassed area with a narrow gravel band running through the middle, and it was on this gravel area where takeoffs and landings were to take place. On the first approach to land, full flap had been selected for a normal landing. As the pilot raised the nose for landing, he over-rotated and allowed the aircraft to climb slightly. When he realised his mistake, he immediately lowered the nose. However, the nosewheel touched down heavily before the resulting descent was detected and arrested. The aircraft bounced a number of times before stopping on the gravel section of the strip. The pilot's restricted experience had not prepared him adequately for operations onto a "bush strip". The narrow gravel band in the centre of the strip was on undulating ground. There were trees close to the approach end of the strip and the surrounding area consisted of scrub. This presented the pilot with a set of visual cues on approach which were different to those to which he had become accustomed during his previous experience. The pilot had been used to closing the throttle over the end of the runway at the aerodrome where he had undertaken his training, and not well beforehand. As a result, the pilot's visual judgement of his approach profile became uncertain and he believed it would be necessary to fly a steeper approach and close the throttle prior to reaching the strip, a deviation from his normal procedure. After descending over the trees and once sure of reaching the strip he closed the throttle, and did not subsequently notice the airspeed. The aircraft was over-rotated at flare point, resulting in a balloon. This was followed by an over-correction downwards which in turn was followed by a hard touchdown and several bounces. A go-around was not attempted from the initial balloon, because the pilot felt that the nose attitude was too high and a go-around might have resulted in a stall. Although he did recognise that the approach was becoming unsafe, he elected to continue because he thought that if he took any different course of action he may have aggravated the situation.

Occurrence summary

Investigation number 198800120
Occurrence date 11/05/1988
Location Mandurah
Report release date 28/10/1988
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 Cessna Aircraft Company
Model 182
Registration VH-PKJ
Serial number 18256314
Operation type Private
Departure point Mandurah WA
Destination Mandurah WA
Damage Substantial

Cessna 180-G, VH-DJS, Albury NSW, 20 March 1987

Summary

The pilot was making a landing approach in moderate crosswind conditions. He commenced the flare at about 15 feet above the runway, with the intention of touching down in a three-point attitude. The aircraft sank rapidly, touched down and bounced to about 10 feet. The pilot maintained rearward pressure on the control column, but did not apply power. The nose of the aircraft dropped sharply and the propeller struck the runway. The aircraft subsequently overturned, coming to rest on the runway centreline. The pilot had completed a check flight on the aircraft the previous day. Conditions during the check flight were more demanding than those at the time of the accident. It was likely that the pilot relaxed his concentration as he flared the aircraft for landing, and was unprepared when the aircraft bounced and subsequently stalled.

Occurrence summary

Investigation number 198702397
Occurrence date 20/03/1987
Location Albury
Report release date 05/06/1987
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 Cessna Aircraft Company
Model 180
Registration VH-DJS
Operation type Business
Departure point Deniliquin NSW
Destination Albury NSW
Damage Substantial

Hughes 269C, VH-UFX, 16 km West of Meda Station WA, 26 May 1988

Summary

The pilot was engaged in mustering operations at 100 feet above ground level and at 60 knots airspeed, when he heard a noise from the rear of the aircraft. He observed the rpm indicators split, with the engine rpm showing an overspeed, and he assumed a clutch cable failure. The aircraft was placed in an autorotational descent. As there was no clear landing area immediately available the pilot turned the aircraft into wind and attempted to find a clear area amongst the trees. The aircraft hit a tree, however, fell to the ground and rolled onto its side. The drive to the main rotors had become disconnected because the cable to the belt drive clutch control tension spring assembly had failed inside the assembly. The cable had been inspected for defects, and none were detected, at the last periodic inspection which occurred 59 hours prior to the accident. The cause of the cable failure could not be determined. The cable had been in service for 2210 hours. It is an "on condition" item, which does not have a specified life. The maintenance system for the aircraft requires that the cable be removed and inspected each 400 hours time in service. Removal is required to inspect the area on the cable that failed. The cable is inspected in situ each 50 hours time in service. The altitude and speed selected by the pilot gave sufficient performance potential for a safe autorotational landing, but the low cruise height significantly reduced the time available to locate and establish an approach into any suitable landing area.

Occurrence summary

Investigation number 198800121
Occurrence date 26/05/1988
Location 16 km West of Meda Station
Report release date 05/04/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Hughes Helicopters
Model 269
Registration VH-UFX
Serial number 470593
Sector Helicopter
Operation type Aerial Work
Departure point Meda Station WA
Destination Meda Station WA
Damage Substantial

Cessna 182E, VH-TSH, Kambalda West WA, 18 June 1988

Summary

Shortly after the pilot applied full power and commenced the take-off roll there was a loud bang and the aircraft yawed violently. The pilot closed the throttle and stopped the aircraft. An inspection disclosed that one complete propeller blade was missing. A detailed inspection of the propeller blade indicated that the blade had failed in the area of the threads at the root of the blade. The fracture surfaces indicated that a fatigue crack had started approximately 500 hours prior to the final flight and that the blade had failed because the remaining unaffected metal could no longer carry the loads involved. The inspection was unable to find any reason for the origin of the fatigue crack. The cracking occurred in an area of the blade which is not visible when the blade is fitted to an aircraft, consequently the cracking could not be disclosed during either preflight or periodic maintenance inspections carried out in accordance with the maintenance system in force at the time of the failure. The blades are normally inspected for cracks at each overhaul. An overhaul is carried out after the blades have been in service for 1500 hours. The blade that failed had been in service for 1052 hours.

Occurrence summary

Investigation number 198800125
Occurrence date 18/06/1988
Location Kambalda West
Report release date 21/02/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Propeller/rotor malfunction
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 182
Registration VH-TSH
Serial number 18254356
Operation type Private
Departure point Kambalda West WA
Destination Kambalda West WA
Damage Substantial