Piper Cherokee PA-32, VH-WSZ, American River South, South Australia, on 6 October 1989

Summary

Circumstances:

The Authorised Landing Area (ALA) at which the accident happened was the home field of the pilot. The ALA comprised two crossed grass runways the longer of which was judged by the pilot to be too bumpy for continued operations. On one end of the shorter runway there was a row of roadside trees. The pilot was in the habit of landing well into the shorter strip towards the trees and reportedly had no problems conducting safe landings. At the time of the accident the wind was reported as being calm and another aircraft was parked on the end of the runway near the trees. On landing the pilot touched down near her usual touchdown point but then felt the aircraft was not decelerating. Aware that there was an aircraft parked at the end of the runway the pilot became concerned that she might not complete the landing safely and initiated a go-around. In attempting to avoid the trees at the end of the runway the aircraft was banked to the left. However, the left wing struck a steel cattle yard and was torn off. The aircraft then crashed through the trees and came to rest in scrub on the other side of the road. Investigation on site showed that the pilot had touched down some 200 metres into the strip and had probably accepted a higher threshold speed than that recommended in the performance charts. In addition, the pilot had neither calculated the landing distance required nor measured the landing distance available. Consequently, she was not aware of the consequences of exceeding the parameters specified in the landing performance charts or the magnitude of the distance penalty that would accrue from such excursions. Post-accident calculations showed that there was sufficient runway length available for a safe landing to be achieved. At the point in the landing roll at which the pilot attempted a go-around a successful take-off could not be achieved within the runway distance remaining before the row of trees. There was much discussion generated during the analysis of the landing distance available and the use of the performance charts. It was discovered that Civil Aviation Authority (CAA) document AGA 6 is misleading, and the CAA have already undertaken to review it to provide better guidance for pilots. This situation was not judged as a causal factor in this accident as the pilot did not consult the subject reference or the performance charts.

Significant Factors:

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

1. The pilot did not consult the performance charts for her intended operation.

2. The pilot was complacent about her aircraft operations.

3. The pilot delayed the decision to carry out a go-around.

Recommendations:

Recommendations concerning the amendment of AGA 6 have already been made to and actioned by the Civil Aviation Authority.

Occurrence summary

Investigation number 198900833
Occurrence date 06/10/1989
Location American River South
State South Australia
Report release date 05/04/1991
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-32
Registration VH-WSZ
Serial number 32-7440026
Sector Piston
Operation type Private
Departure point Penneshaw SA
Destination American River South SA
Damage Substantial

Transavia PL12-T300, VH-JSO, Lilydale, Tasmania, on 29 March 1989

Summary

Circumstances:

The pilot was conducting spreading operations. On the 51st take-off for the day, at a speed of about 35 knots and about 100 metres from the commencement of the take-off run, the aircraft started to swing to the right. The pilot realised that he had no control over the swing, so he closed the throttle and applied maximum braking. The aircraft continued to swing to the right, left the confines of the strip, and collided with a cattle yard. Examination of the aircraft showed that the right main gear oleo rod end fitting had failed. This had allowed the oleo to swing under the stubwing, jamming the wheel, resulting in loss of directional control. Inspection also revealed that the left landing gear rod end fitting was cracked. Both fittings were then subjected to metallurgical examination. This determined that the rod ends were of inferior quality with a hardness and tensile strength approximately 60 of other rod ends previously examined. This would indicate that the rod ends were not of aircraft standard. The source of supply of these components was not determined. 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 main landing gear oleo rod ends were not of an aircraft quality.

2. The right hand main landing gear rod end failed.

3. Directional control of the aircraft was lost.

Recommendations:

It is recommended that the Civil Aviation Authority (CAA) take appropriate measures to determine the source and distribution of the substandard landing gear oleo rod end fittings, to remove them from service and stock holdings. CAA Materials Evaluation Facility Lab Note No 813 refers.

Occurrence summary

Investigation number 198901540
Occurrence date 29/03/1989
Location Lilydale
State Tasmania
Report release date 27/03/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Transavia Corp Pty Ltd
Model PL-12
Registration VH-JSO
Serial number G467
Sector Piston
Operation type Aerial Work
Departure point Lilydale TAS
Destination Lilydale TAS
Damage Substantial

Grumman GA-7 Cougar, VH-UNP, 2 km north-east of Cessnock Airport, New South Wales, on 7 August 1989

Summary

Circumstances:

The student pilot was undergoing a period of dual circuit training at night as part of an initial multi engine aircraft endorsement. Another student pilot, who was also programmed for night circuit training, was on board the aircraft as an observer. Weather conditions were reported as suitable for night circuit training, although there was no visible horizon. There were no reports of turbulence. Night circuits were conducted to the east of the aerodrome due to high terrain on the western edge of the circuit area. The student pilot completed four circuits on runway 35, before the instructor took over control of the aircraft and demonstrated a circuit. After landing, the instructor selected flaps up, applied full power to both engines and handed over control to the student. After take-off the landing gear was retracted and the initial climb proceeded normally until the aircraft reached a height of about 190 feet above ground level (400 feet above sea level). As the aircraft was accelerating to a climb speed of 95 knots, the left engine, without any prior warning suffered a complete loss of power. The instructor immediately resumed control, identified the failed engine, and feathered the propellor. During this activity the aircraft descended to 340 feet above sea level. The airspeed was stabilised at the recommended single engine climb speed of 85 knots, and the aircraft was banked slightly towards the right engine. As the vertical speed indicator and altimeter indicated that the aircraft was not climbing, the instructor told the student to transmit a Mayday call. This was received by Sydney Flight Service who declared a Distress phase. The instructor, being aware of higher terrain to the north of the aerodrome, commenced a gentle turn to the right until the aircraft was heading approximately 150 degrees magnetic. Darkness prevented an off aerodrome forced landing being considered as a suitable option. Shortly after the completion of the turn, the right wing struck a pylon of a 330 KV Transmission line approximately 347 feet above sea level. The aircraft cartwheeled through the transmission lines and dived vertically to the ground. As the aircraft passed through the power lines the failed left engine, propeller, and cowling were severed from the wing. The aircraft came to rest in a slightly nose low, right wing down attitude. The right engine was partially buried in soft earth and torn away from the right wing. Although a fire broke out in the accessory section, it subsequently self-extinguished. A considerable amount of fuel escaped from broken fuel lines. All three occupants were seriously injured. The observer in the rear seat suffered two broken legs, but was able to vacate the cabin without assistance, although he subsequently had no recollection of how he did so. The student assisted the instructor from the aircraft then returned to the cockpit to switch off electrical power. Police and emergency services arrived at the scene with minimum delay. The occupants were given first aid then conveyed to hospital. A technical investigation, which included operating the left engine in a test bed, revealed the cause of the power loss to be air ingestion into the left engine fuel system. A loose connection was found where the left engine priming solenoid is located in the fuel line. This permitted the engine driven fuel pump to draw air instead of fuel and resulted in fuel starvation at the carburettor. Maintenance records indicated that no work had been carried out on the left engine primer solenoid since the aircraft arrived in Australia in late 1988. It was not possible to determine why the connector at the priming solenoid had loosened sufficiently to permit air ingestion. The reason for the inability of the aircraft to climb on one engine was not determined. Aircraft having a maximum take-off weight of less than 5700 kgs are not certificated to provide a minimum net single engine climb gradient following an engine failure after take-off. The carriage of the observer was considered to have had an adverse effect on the asymmetric performance of the aircraft. In addition, the general level of cockpit instrument illumination, particularly of the skid ball, may not have facilitated precise attitude control by the pilot.

Significant Factors:

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

1. Inadequate inspection/maintenance of fuel system.

2. Loose fuel line connection at left engine priming solenoid.

3. Sudden, total loss of left engine power at a critical stage of flight.

4. Inadequate asymmetric performance of the aircraft under the conditions existing at the time.

5. Darkness.

6. Pilot unable to see and avoid fixed obstruction.

Recommendations:

It is recommended that the Civil Aviation Authority

1. Review the cockpit lighting of Grumman Cougar GA-7 aircraft, specifically to improve illumination of the turn and balance indicator.

2. Advise operators to consider the requirement that multi engine aircraft of less than 5700 kgs MTOW, engaged in night flying circuit training to be loaded in accordance with IFR Aerial Work limitations.

Occurrence summary

Investigation number 198902571
Occurrence date 07/08/1989
Location 2 km north-east of Cessnock Airport
State New South Wales
Report release date 31/10/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Grumman American Aviation Corp
Model GA-7
Registration VH-UNP
Serial number 390GA
Sector Piston
Operation type Flying Training
Departure point Cessnock NSW
Destination Cessnock NSW
Damage Destroyed

De Havilland DH-82A, VH-LJM, 2 km south-east of Coldstream Airfield, Victoria, on 20 November 1988

Summary

Circumstances:

The pilot was flying a right hand circuit for Runway 35 at a height of about 500 feet above ground level. The aircraft was observed at a base turn position to suddenly bank about 30 degrees to the right, and then to adopt a nose low attitude and begin rotating to the right. This rotation continued until the aircraft struck the ground. No fault was subsequently found with the aircraft which might have contributed to the accident. The pilot reported that he had reduced engine power on the downwind leg because the aircraft speed was too high. He recalled that after the aircraft began rotating, he had pulled the control column backwards, in an attempt to raise the nose of the aircraft and recover to normal flight, but this had no effect. The behaviour of the aircraft immediately prior to impact was consistent with its speed decreasing to the point where the wing(s) stalled and the aircraft entered a spin to the right. The pilot had completed an aerobatic endorsement (including spin entry and recovery) on the aircraft type some five months before the accident. However, he reportedly had only four opportunities to practice spin recovery since then. The attempt by the pilot to recover from the spin by moving the control stick backwards was incorrect and was probably a spontaneous action on his part triggered by the sudden onset of the spin and the low height above ground level at which it occurred.

Significant Factors:

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

1. The pilot did not maintain sufficient airspeed for the conditions involved.

2. The aircraft stalled and entered a spin to the right.

3. In what was probably a spontaneous action on his part, the pilot applied an incorrect technique in attempting to recover from the spin.

Recommendations:

Examination of the cockpit areas of the aircraft showed that the left hand shoulder harness attachment point for the front seat safety harness had failed, possibly contributing to the injuries received by the passenger. The shoulder harness arrangement is that the shoulder straps are attached to a common end fitting which is equipped with a pulley. The pulley is free to move laterally on a traverse cable which is attached via lugs bolted to the left and right upper fuselage longerons. In this case, the lug on the left side had separated from its longeron when the rear of the two attaching bolts failed. The failed bolt was not recovered but probably failed due to a combination of tension, bending and shear loads. The recommendation is made that the Civil Aviation Authority consider requiring either modification of the lug to prevent deformation of its rear end, or replacement of the rear bolt with a larger diameter bolt to prevent local bending of the bolt.

Occurrence summary

Investigation number 198801406
Occurrence date 20/11/1988
Location 2 km south-east of Coldstream Airfield
State Victoria
Report release date 12/06/1990
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 de Havilland Aircraft
Model DH-82
Registration VH-LJM
Serial number 996
Sector Piston
Operation type Private
Departure point Coldstream VIC
Destination Coldstream VIC
Damage Substantial

Aerospatiale AS350B, VH-AFO, Grass Tree Hill (11 km NW of Cambridge) TAS, 29 July 1988

Summary

The pilot and the helicopter were involved in a training exercise for trainee fireman. The task was to teach safety around helicopters, especially relating to fire fighting activities. The State Fire Commission provided new sling equipment, purchased from a ship chandler. Experienced fire fighting personnel had prepared several sling loads in advance for the pilot. The strop chosen to lift the 500kg water bladder was 20 metres long. The purpose of the long strop was to enable the helicopter to lower the water bladder to firemen working in low scrub. The strop had been assembled by passing each end of the rope around a metal eyelet and whipping it because the polyester rope was not suitable for splicing. Visually the whipped ends looked satisfactory.

The helicopter lifted the load to about 150 feet above the ground and was accelerating through about 20 knots when the pilot heard a loud bang, felt a vibration through the airframe and realised that the load had detached from the helicopter. He made a precautionary landing nearby. The rope of the strop had slipped through the whipped section at the eyelet where it attached to the water bladder with a shackle. The rope had recoiled, damaged one of the three main rotor blades, ripped the right hand horizontal stabilizer and wrapped around the tail boom.

The known safe working load limits for the individual items comprising the strop were more than adequate for the intended sling loads. The new strop had never been proof tested; nor was there any indication that the helicopter company or the Fire Commission had instructed the manufacturer to proof test the strops.

Occurrence summary

Investigation number 198801393
Occurrence date 29/07/1988
Location Grass Tree Hill (11 km NW of Cambridge)
Report release date 21/02/1989
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 None

Aircraft details

Manufacturer Aerospatiale Industries
Model AS350
Registration VH-AFO
Serial number 1105
Sector Helicopter
Operation type Aerial Work
Departure point Grass Tree Hill TAS
Destination Grass Tree Hill TAS
Damage Substantial

De Havilland DH 82-A, VH-ASC, Bankstown NSW, 2 August 1986

Summary

The pilot was taxying the aircraft along a gravel path in the direction of a run-up area for runway 36. The duty runway was 29, and the pilot's request to depart into the North was not approved. A gentle turn was made to join a marked taxyway, but before the aircraft reached this taxyway the left wing struck a metal sign. The pilot was aware of the location of the sign, but had inadvertently overlooked its presence.

Occurrence summary

Investigation number 198602343
Occurrence date 02/08/1986
Location Bankstown
Report release date 03/09/1986
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer de Havilland Aircraft
Model DH-82
Registration VH-ASC
Operation type Charter
Departure point Bankstown NSW
Destination Bankstown NSW
Damage Substantial

Heintz Zenith CH-200, VH-IJZ, Wollongong NSW, 17 April 1988

Summary

The pilot reported that he intended to carry out a touch and go landing. The approach was normal but after touchdown, the aircraft started to drift to the left. The pilot advised that because of his familiarity with hang glider operations, he used the wrong rudder in an attempt to correct the situation. The nose swung rapidly to the left and the nose gear collapsed. The aircraft came to rest at the edge of the runway.

Occurrence summary

Investigation number 198802358
Occurrence date 17/04/1988
Location Wollongong
Report release date 12/05/1988
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 Zenith Aircraft Company
Model CH-200
Registration VH-IJZ
Serial number N-82
Operation type Private
Departure point Wedderburn NSW
Destination Wollongong NSW
Damage Substantial

Airborne Edge Trike, not registered, 14 km north of Coleambally, New South Wales, on 2 January 1990

Summary

Circumstances:

The pilot was assessing a new powered trike hang glider which had greater performance capabilities than his own aircraft. He successfully completed several circuits before landing for a short period about one kilometre from the witnesses. The aircraft became airborne again, climbed to about 100 feet and performed a series of short climb and descent manoeuvers. It then entered a very steep angled climb, described by the witness as 80 degrees. At about 300 feet, the sound of the engine ceased, the nose pitched down, and the aircraft entered a series of three "tuck and tumbles", similar to an uncontrolled outside loop. On the third tuck and tumble, both wings failed and came together, and the aircraft fell straight to the ground. At some point, the emergency parachute handle was pulled but there was insufficient altitude remaining and the parachute did not deploy from the container. No pre-existing defects were found with the aircraft. The investigation determined that during the break-up sequence the seat area separated from the section containing the engine, which was still running at ground impact. Ground testing of the engine revealed no defects and the engine continued to run satisfactorily up to simulated angles of 35 degrees of climb. This, together with the 50 degrees freedom of movement for the control bar, would allow a very steep apparent angle of climb to ground observers. It is most likely that the pilot, once the aircraft attained this attitude, closed the throttle, and pulled back on the control bar. This probably initiated the tuck and tumble sequence. It was found that the parachute was attached to the engine, not the seat frame, and that the parachute's performance rating did not match the performance rating of the aircraft.

Significant Factors:

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

1. The pilot's experience was on considerably lesser powered and lower performing ultra-light aircraft. 2. Whilst attempting a very steep climb, the pilot applied incorrect recovery technique.

Recommendations:

1. It is recommended that the Civil Aviation Authority (CAA) and the Australian Ultralight Federation (AUF) review training standards and experience requirements for ultra-light pilots intending to upgrade to aircraft with significantly enhanced performance characteristics.

2. The AUF should encourage manufacturers of trike aircraft fitted with parachutes to ensure that the emergency parachute is attached to the seat frame and is compatible with the performance of the aircraft.

Occurrence summary

Investigation number 199000034
Occurrence date 02/01/1990
Location 14 km north of Coleambally
State New South Wales
Report release date 10/05/1990
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 Airborne Australia
Model Edge Trike
Registration Not registered
Serial number AB-532-000
Sector Piston
Operation type Private
Departure point Talinga Station NSW
Destination Talinga Station NSW
Damage Destroyed

Mitsubishi MU-2B-25K, VH-MUK, Toowoomba QLD, 14 July 1987

Summary

The pilot stated that the wind was blowing directly across the strip and he joined the circuit for a landing on runway 29. He reported that when the aircraft was on final approach it encountered a significant tailwind, and a missed approach was carried out, followed by a "tear-drop" style turn to align the aircraft on final for runway 11. The pilot stated that after touching down on the mainwheels, the nosewheel was lowered and he heard a bang before the nose of the aircraft contacted the runway. The aircraft slid along the runway before coming to rest just off the sealed surface. An inspection of the landing gear assembly revealed that the nosegear downlock linkage failed due to overload forces causing the nosegear to retract. The landing gear mechanism was also bent by overload forces. No evidence could be found to indicate that defects in the landing gear system existed prior to this landing. The nature of the failure of the nosegear is consistent with heavy nosewheel runway contact.

Occurrence summary

Investigation number 198703487
Occurrence date 14/07/1987
Location Toowoomba
Report release date 28/09/1987
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 Mitsubishi Aircraft Int
Model MU-2
Registration VH-MUK
Serial number 310
Operation type Charter
Departure point Moomba SA
Destination Toowoomba QLD
Damage Substantial

Maxair Drifter XP503, Not Registered, Taylors Arm NSW, 31 May 1987

Summary

The aircraft had completed several successful flights during the day. At the completion of a power off descent, the pilot rapidly opened the throttle. The engine began running roughly and then failed completely. During the subsequent glide approach, for a forced landing, the aircraft collided with powerlines which crossed a gully about 350 feet above the ground. One line contacted the pilot's throat, inflicting severe lacerations, and the aircraft descended to the ground out of control. An inspection of the engine did not reveal any defects that could have contributed to the occurrence. This particular type of engine, which has inverted cylinders , floods quickly with rapid advance of the throttle. This flooding with unburnt fuel, swamps the spark plugs causing the engine to fail.

Occurrence summary

Investigation number 198702459
Occurrence date 31/05/1987
Location Taylors Arm
Report release date 20/11/1987
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Unknown
Model Maxair Drifter XP503
Registration Not registered
Operation type Sports Aviation
Departure point Taylors Arm NSW
Destination Taylors Arm NSW
Damage Substantial