Morane Saulnier Rallye MS 880B, VH-UQG, Wellington NSW, 24 January 1985

Summary

The pilot had diverted to Wellington because of thick bushfire smoke on his intended track. Take-off was initiated after the smoke had cleared, however shortly after becoming airborne the aircraft sank towards the ground. The pilot subsequently advised that although the engine was developing full power he was unable to prevent the sink from continuing until the aircraft struck the ground heavily, 210 metres beyond the boundary fence of the strip. The 05 strip was used for take-off into a north-easterly breeze. However a witness about 2 kilometres away, along the take-off path, reported that the wind there was from the south. It is likely that at about 200 feet agl the aircraft experienced a head to tail wind change. The pilot attempted to regain airspeed by lowering the nose but the low altitude and rising ground ahead prevented sufficient airspeed to be recovered.

Occurrence summary

Investigation number 198502511
Occurrence date 24/01/1985
Location Wellington
Report release date 01/08/1985
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of control
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer SOCATA-Groupe Aerospatiale
Model MS.880
Registration VH-UQG
Operation type Business
Departure point Wellington NSW
Destination Mudgee NSW
Damage Substantial

Britten-Norman BN2-A6 Islander, VH-RTP, Mabuiag Island, Queensland, on 30 May 1990

Summary

Circumstances:

The pilot reported that he planned to do a short-field landing to ensure that minimum braking action would be necessary on the wet grass surface. On late final approach, the aircraft encountered a down draft from which the pilot was unable to recover in time to avoid striking the lip of the strip. The left main gear was bent back as a result.

Occurrence summary

Investigation number 199003072
Occurrence date 30/05/1990
Location Mabuiag Island
State Queensland
Report release date 05/06/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Pilatus Britten-Norman Ltd
Model BN2
Registration VH-RTP
Serial number 79
Sector Piston
Operation type Charter
Departure point Horn Island QLD
Destination Mabuiag Island QLD
Damage Substantial

Britten-Norman BN2-A8 Islander, VH-SLM, 30 km NE of Rockhampton QLD, 13 January 1988

Summary

This flight was the last of a multi-stage flight from Rockhampton. A dip stick was used to determine the quantity of fuel on the aircraft prior to refuelling for the flight. One tank was again checked after refuelling and the pilot was satisfied that sufficient fuel was carried. He was in the habit of disregarding the fuel gauges as being inaccurate. Both engines subsequently failed towards the end of the flight, however, the pilot was able to carry out a successful forced landing on a nearby strip. An inspection of the aircraft fuel system revealed that only unuseable fuel remained in the aircraft fuel tanks. A fuel system calibration showed that the gauges were accurate and that the dip stick was over-reading by about 15 US gallons (57 litres). This resulted in the fuel onboard being insufficient to complete the flight. The dip stick had been with the aircraft when it was imported some six years earlier.

Occurrence summary

Investigation number 198102560
Occurrence date 13/01/1988
Location 30 km NE of Rockhampton
Report release date 16/08/1988
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Airparts NZ Ltd
Model FU-24
Registration VH-EUO
Serial number 112
Operation type Aerial Work
Departure point Marble Island QLD
Destination Rockhampton QLD
Damage Nil

North American Rockwell Ayers Thrush S2-R, VH-JBN, Mungindi NSW, 2 December 1984

Summary

At the conclusion of night spraying operations the pilot departed for Mungindi. Witnesses at the town saw the aircraft overflying at a low height and heading towards the aerodrome, which is about 7 kilometres from the town. Engine noise was then heard to cease and sounds of impact followed. The aircraft had struck the ground 5 kilometres from the aerodrome, and a post-impact fire had engulfed the wreckage. No fault could be found with the aircraft or its systems that could have contributed to the accident. Specialist medical opinion indicated that the pilot had suffered a heart attack before the fire occurred. It was not possible to determine to what extent, if any, the pilot was able to control the aircraft prior to impact.

Occurrence summary

Investigation number 198401428
Occurrence date 02/12/1984
Location Mungindi
Report release date 27/08/1985
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 Ayres Corporation
Model S2R
Registration VH-JBN
Operation type Aerial Work
Departure point "Iolanthe" Property, 50 km of ESE Mungindi NSW
Destination Mungindi NSW
Damage Destroyed

De Havilland DH-60M Gipsy Moth, VH-UQV, Maitland Aerodrome NSW, 22 October 1989

Summary

An early morning flight was arranged between the owners of the Gipsy Moth VH-UQV and the owner of a Tiger Moth VH-DDA with the intention of photographing the Gipsy Moth from the air. The owner of VH-DDA agreed to fly in the Gipsy Moth and occupy the rear seat whilst the pilot-in-command occupied the front seat. The Tiger Moth was flown by the other owner of the Gipsy Moth. The Gipsy Moth was flown by the rear seat pilot for the first part of the flight. At the completion of the photography, which was conducted in the circuit area at Maitland, the pilot-in-command took control of the aircraft. The aircraft was flown to the north-east of the aerodrome to the Hunter River where it was descended to fly at a low height over the river. With the pilot in-command still at the controls, the aircraft returned to the aerodrome at a height of about 500 feet. After passing the aerodrome southern boundary, the aircraft entered a steep turn to the left. The non-flying pilot in the rear seat reported the aircraft, whilst passing through a north westerly heading, was rolled to the right to avoid a tree. The right wing struck and severed a cable of an 11,000 volt power line causing the aircraft to cartwheel into the ground, within the aerodrome boundary. This accident was not the subject of a formal on scene investigation.

Occurrence summary

Investigation number 198902582
Occurrence date 22/10/1989
Location Maitland Aerodrome
Report release date 29/11/1989
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 de Havilland Aircraft
Model DH-60
Registration VH-UQV
Serial number 783
Operation type Private
Departure point Maitland NSW
Destination Maitland NSW
Damage Substantial

Lightwing Twin Seat Ultralight, Amity Point QLD, 23 June 1989

Summary

During cruise, the engine started to run roughly. The pilot found that he could not maintain altitude and elected to land on a narrow road, this being the only area clear of trees. During the landing, the wing struck the ground. The cause of the engine problem was not determined. This accident was not the subject of a formal on-scene investigation.

Occurrence summary

Investigation number 198903842
Occurrence date 23/06/1989
Location Amity Point
Report release date 07/11/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Howard Hughes Engineering P/L
Model Lightwing Twin Seat Ultralight
Serial number LW1 001
Operation type Sports Aviation
Departure point Kooralbyn, QLD
Destination Jacobs Well, QLD
Damage Substantial

Kavanagh Balloons Pty Ltd D-77, VH-HQV, Griffith NSW, 25 March 1989

Summary

On landing the basket touched down once, lifted back into the air and touched down a second time about 10 metres further on. The landing was not heavy and it was described as normal by an expert witness. The basket remained upright throughout the landing. One of the passengers apparently shifted position during the landing sequence and this resulted in her receiving a broken ankle. This accident was not the subject of an on-scene investigation.

Occurrence summary

Investigation number 198900235
Occurrence date 25/03/1989
Location Griffith
Report release date 08/05/1989
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 Serious

Aircraft details

Manufacturer Kavanagh Balloons
Model D
Registration VH-HQV
Serial number KB 067
Operation type Ballooning
Departure point Griffith NSW
Destination Griffith NSW
Damage Nil

Kavanagh Balloons D-105, VH-BOK, 5 km north-east of Cessnock Airport, New South Wales, on 15 October 1989

Summary

Circumstances:

Towards the completion of a scenic flight with five adult passengers on board, the pilot descended the balloon to a height of approximately 200 feet above ground level and commenced searching for a suitable landing site. His initial selection was subsequently abandoned to avoid frightening an injured horse. The balloon with limited fuel remaining continued at low level, passing over timbered country before commencing a deflated landing into a semi cleared area. The area was surrounded by tall trees to the left, right and rear of the flight path. A two-wire high voltage set of powerlines located just ahead of the pilot's proposed landing area, were not sighted by a ground retrieval crew member, who was in the vicinity of the landing site and in radio contact with the pilot, nor apparently by the pilot until late into the landing. The passengers had not been briefed to assist in observing for and reporting powerlines. The pilot then issued instructions which his passengers understood to mean that they prepare to exit the balloon basket. When approximately one metre above the ground, the first passenger evacuated the basket followed by the pilot, who had the fabric covered metal parachute vent line wrapped in a spiral around his forearm. With the load reduced the balloon began to ascend. One flying wire supporting the balloon basket at the lower section of the balloon envelope, contacted the powerlines before the balloon descended again. An electrical discharge was heard, and one powerline was severed. As the basket neared the ground a second and third passenger exited. The pilot was then observed lying on the ground fatally injured, apparently having received a high voltage discharge via the parachute vent line. The line had then detached from around his forearm. A fourth passenger then vacated the basket, leaving one passenger on board. With the release of the parachute vent line the exhaust vent closed and as there was still sufficient buoyancy retained within the envelope, the balloon slowly re-ascended. When at an estimated height of 10 metres above the ground, the remaining passenger was observed to fall from the balloon basket and receive fatal injuries. The balloon continued to drift for approximately two kilometres before settling to the ground in heavily timbered country. The pilot's technique of wrapping the parachute vent line around his wrist and forearm would have made rapid deflation difficult. His actions in preparing passengers to jump and his decision to exit the basket prior to landing, were totally alien to the normal and emergency modus operandi. It is believed that a previous similar type fatal accident involving a balloon colliding with a powerline, may have influenced his behaviour. Subsequent trials indicated that it is extremely difficult to evacuate all passengers from a basket in a short time frame without pre-warning, established drills, and orderly implementation. The weather conditions were calm and clear, but the early morning ambient light conditions would have made detection of the powerlines difficult. The area selected for the landing was the only alternative available considering the meteorological conditions and fuel remaining. The size of the area should have been within the capabilities of the pilot and balloon had there been no powerlines across the flight path. Stringent obstacle clear gradient requirements exist for the selection of take-off sites, but not for landing sites. Despite some instrumentation deficiencies, the balloon and all of its relevant equipment was serviceable and had been maintained in accordance with approved procedures. Electrical bonding and insulation properties of the balloon were considered to be inherent design deficiencies for this type of aircraft, thereby permitting differing electrical potentials to exist between individual components, particularly in the event of powerline contact.

Significant Factors:

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

1. The aborted landing to avoid injured stock placed the pilot in an emergency landing situation.

2. The lack of timely detection of powerlines deprived the pilot of vital pre-landing information.

3. The evacuation of the basket prior to touchdown made pilot control of the balloon buoyancy difficult.

4. The pilot could not deflate the envelope before the balloon ascended into the powerlines.

5. Lack of effective electrical insulation and bonding properties facilitated the conduct of the electrical discharge to earth.

6. The pilot received a fatal electrical high voltage charge through the parachute vent line which was wrapped around his forearm.

7. The balloon contained sufficient buoyancy to ascend after the parachute vent line became free and the parachute vent closed.

8. The pilot's actions may have been influenced by a similar previous accident.

Recommendations:

It is recommended that the Civil Aviation Authority in conjunction with the Commercial Balloon Operators and the Australian Ballooning Federation, reassess existing requirements for commercial balloon operations and surveillance of standards and in particular give consideration to

1. Initiating a research and development programme into an on-board, electronic, directional, powerline detection device.

2. Redefining the Flight Manual Emergency Landing procedures concerning the briefing of passengers before ground contact, with particular emphasis upon orderly basket evacuation methods.

3. Initiating manufacturer approved methods of reducing the amount of exposed metal and providing electrical bonding of all metal components to achieve a neutral electrical potential difference between any two components.

4. Defining minimum obstacle clear approach parameters and gradients for commercial balloon landing sites consistent with balloon size and prevailing meteorological conditions.

5. Ensuring, as far as is practicable, that at least one member of the retrieve crew is either present at the proposed landing site, or in such other position with unrestricted views, as to be able to brief the pilot of obstacles and assist with rapid deflations and evacuations as required.

Occurrence summary

Investigation number 198900017
Occurrence date 15/10/1989
Location 5 km north-east of Cessnock Airport
State New South Wales
Report release date 28/09/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wirestrike
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Kavanagh Balloons
Model D-105
Registration VH-BOK
Serial number KB-027
Sector Balloon
Operation type Ballooning
Departure point 9 km N of Cessnock Airport NSW
Destination 5 km NE of Cessnock Airport NSW
Damage Minor

Kavanagh Hot Air Balloon E-260, VH-NMS, 14 km SSE of Alice Springs Airport NT, 13 August 1989

Summary

Five hot air balloons, including the two involved in the collision, VH-NMS and VH-WMS, were operating tourist charter flights from the same launch area. Flight plans had been submitted and correctly co-ordinated. All the balloons were ready at about the same time and took off within minutes of each other. VH-WMS was airborne about two minutes ahead of VH-NMS. The pilot of VH-WMS then requested an Airways Clearance for both his aircraft and VH-NMS. A clearance was issued for them to operate in the Alice Springs Control Zone not above 4000 feet. VH-WMS acknowledged for both aircraft. This clearance did not make specific reference for them to operate as a formation, but to operate in company. VH-WMS climbed to 4000 feet (2000 feet above ground level) and drifted in a westerly direction. Witness evidence revealed that the pilot did not use the burner for a considerable period of time while pointing out places of interest to the passengers. A video film taken from another balloon indicates that VH-WMS appeared to be descending at this time, while VH-NMS was climbing to follow it. During the climb the pilot of VH-NMS would have lost visual contact with VH-WMS due to his envelope causing a blind area above. VH-WMS was not fitted with the mandatory instrument package, without which the pilot would have been unable to accurately ascertain his altitude or judge his vertical movement. The pilot was wearing a wrist altimeter. Several of the passengers in VH-WMS had noted that the other balloon, VH-NMS, was below and climbing towards them from the east. They reported that it seemed to close on them at a fast rate until its envelope struck their basket. Evidence indicates that neither of the pilots were in contact with one another. Both balloons were equipped with UHF (Ultra High Frequency) radios operating on the same frequency. The basket of VH-WMS contacted the envelope of VH-NMS just below the velcro rip panel, tearing a hole in the fabric panel, which was under tension from containing the large mass of hot air within the envelope. Tearing continued through adjacent panels and seams, creating a hole large enough for the basket of VH-WMS to enter and proceed more than half way down into the interior of the envelope. At the point where the basket of VH-WMS moved inside the envelope, it would have contacted and fouled against the control lines for the velcro rip panel vent, initiating activation of the rip panel Capewell safety locks, and as it moved further inside would have contacted the control line for the parachute vent. The parachute vent line remained fouled around the outboard end of the basket of VH-WMS as it swung clear of the hole in the envelope of VH-NMS. This caused the velcro rip panel to fully open as the two balloons separated. VH-NMS then descended as hot air escaped through the damaged envelope panels and opened velcro rip panel, causing the envelope to elongate and rapidly collapse. The degree of disruption of the envelope was such that the balloon could not remain inflated. The basket, with the deflated envelope trailing above it, then plummeted to the ground. The investigation did not reveal any abnormalities or defects to the balloon, its envelope material or methods of manufacture, which could be considered to have contributed to the accident. Following the accident, the pilot of VH-WMS mentioned to one of his passengers that he had not noticed the other balloon before they collided. Subsequently, the pilot of VH-WMS, following legal advice, refused to co-operate fully with the Investigator-In-Charge in spite of having been summonsed under the provisions of the Air Navigation Act. The Company's Operations Manual states - "FORMATION FLIGHT When two or more balloons are flying together the upper balloon must give way. Avoid basket to envelope contact when taking off or in close proximity."

Occurrence summary

Investigation number 198900820
Occurrence date 13/08/1989
Location 14 km SSE of Alice Springs Airport
Report release date 28/11/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Airborne collision
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Thunder & Colt Balloons
Model 240
Registration VH-NMS
Serial number KB 078
Operation type Ballooning
Departure point 14km SE of Alice Springs Airport NT
Destination Old South Road, Alice Springs, NT
Damage Destroyed

Britten Norman BN2-A21 Islander, VH-FCJ, Mabuiag Island, Queensland, on 9 June 1990

Summary

Circumstances:

Well before the flight was due to depart, the company agent at Mabuiag Island endeavoured to warn the operator that the strip was wet and unsuitable for operations. This attempt to communicate failed due to a local fault in the Telecom system. The pilot was aware of a previous recent accident where a pilot landed short of the runway lip. When he arrived, he assessed the strip as suitable and landed well into the strip. By the time that he discovered that the strip was slippery, it was too late to go around. When it became obvious that he could not stop within the confines of the strip by using normal braking, he attempted a ground loop. The aircraft slid sideways off the end of the strip onto a beach.

Occurrence summary

Investigation number 199003074
Occurrence date 09/06/1990
Location Mabuiag Island
State Queensland
Report release date 29/06/1990
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 None

Aircraft details

Manufacturer Pilatus Britten-Norman Ltd
Model BN2
Registration VH-FCJ
Serial number 448
Sector Piston
Operation type Charter
Departure point Horn Island QLD
Destination Mabuiag Island QLD
Damage Substantial