Aviation safety investigations & reports

Loss of control, 7 km WSW of Tamworth Airport, NSW, VH-FIN

Investigation number:
Status: Completed
Investigation completed


Download Final Report
[Download  PDF: 928KB]

At about 1326 Eastern Daylight-saving Time on 7 March 2005, the pilot of a Cessna Aircraft Company 310R, registered VH-FIN, took off from runway 30 Right at Tamworth Airport, for Scone, NSW. Approximately 1 minute after becoming airborne, the pilot reported flight control difficulties. At about 1329, the aircraft impacted the ground in a cleared paddock about 7 km west-south-west of the airport. The pilot was fatally injured and the aircraft was destroyed by the impact forces and post-impact fire.

Examination of the aircraft's mechanical flight control systems, autopilot and electric trim system did not reveal any evidence of pre-impact malfunction. Those results, however, were inconclusive due to the extensive impact and fire damage. A bent hand tool found in the wreckage was not implicated in the development of the accident.

A periodic maintenance inspection carried out in the days before the flight resulted in the rudder trim tab being set at the full right position and possibly aileron and elevator trim tabs being set at non-neutral positions prior to the flight. There were indications that the pilot was rushed and probably overlooked the rudder and aileron trim tab settings prior to takeoff. The aircraft flight path reported by witnesses was found to be consistent with the effect of abnormal rudder and/or aileron trim tab settings.

The investigation found that aircraft operating checklists produced by aircraft operators did not always include the autopilot and electric trim procedures located in the supplements of aircraft operating handbooks/flight manuals. At the time of the accident, the training and guidance generally provided to pilots did not emphasise the management of flight control difficulties including autopilot and electric trim related difficulties.

Following the accident, the aircraft operator and the maintenance provider advised that they had reviewed and amended some procedures. The Civil Aviation Safety Authority advised that a Civil Aviation Advisory Publication titled Multi-engine Aeroplane Operations and Training will be issued by July 2007 and that three items have been forwarded to the Safety Promotion Branch for consideration/action.

Download Final Report
[Download  PDF: 928KB]

Interim Factual

At about 1326 Eastern Daylight-saving Time on 7 March 2005, the pilot of a Cessna Aircraft Company 310R, registered VH-FIN, commenced takeoff from runway 30 right at Tamworth on a ferry flight to Scone, NSW. Witnesses reported that the pilot initially maintained the runway heading, as cleared by air traffic control (ATC). When the aircraft was between 800 and 1,000 ft above ground level (AGL) and while making a shallow banked turn to the left, the pilot broadcast to ATC that he was experiencing 'control difficulties'. Upon or shortly after reaching an early downwind position the aircraft was observed to enter a steep nose-down descent. While there were some inconsistencies in the available witness reports, it appeared that the aircraft may have rolled about its longitudinal axis at some stage on the final descent. The aircraft impacted the ground in a cleared paddock about 4 NM west-south-west of Tamworth airport, fatally injuring the sole occupant pilot of the aircraft. The aircraft was destroyed by the impact forces and post-impact fire.

The pilot was appropriately licensed and rated, held a valid class 1 medical certificate and was reported as being fit to fly. The results of post mortem examination and toxicology screening found no evidence of any physiological factor that may have impaired the pilot's performance during the occurrence flight.

The aircraft was maintained under a Civil Aviation Safety Authority (CASA) approved maintenance system. The aircraft had been subject to scheduled maintenance by a CASA approved maintenance facility immediately prior to the accident. The aircraft had a current maintenance release and there were no recorded defects at the time of the accident.

The investigation calculated the aircraft's weight and balance based on fuel load records and estimated fuel burn rates for previous operations, including engine runs relating to the maintenance activity completed immediately prior to the occurrence flight. The investigation estimated that at the time of the occurrence, the aircraft was operating below the maximum permitted take-off weight and within the stipulated centre of gravity limits.

The Automatic Terminal Information Service (ATIS) current at the time of the occurrence, reported that the wind was variable at eight knots with occasional crosswind of eight knots, CAVOK1, temperature 27°C and a calculated mean sea level pressure datum (QNH) of 1019 hPa.

The wreckage trail extended over a distance of about 232 m. Ground impact marks and other physical evidence indicated that the aircraft struck the ground in an upright slightly right wing low, 35 to 50 degrees nose-down attitude, and that both engines were developing significant power at the time of impact.

During the on-site examination of the wreckage, investigators located a tool that would normally not be expected to be carried on the aircraft. Metallurgical analysis showed no evidence that the tool had been trapped within, or had in any way interfered with the control systems of the aircraft.

The pilot did not specifically transmit a distress call to ATC during the occurrence. The pilot advised that the aircraft was subject to 'control difficulties', that he was 'losing direction of the aircraft' and that the autopilot was 'not on'.

The aircraft was equipped with a Cessna 400B Nav-O-Matic Autopilot System. The autopilot controller recovered from the site showed evidence of thermal damage to a wire within the controller, consistent with current overload (Figure 1). That damage was inconsistent with post-impact fire damage. The ATSB is awaiting data from the manufacturer and other specialist agencies regarding the effect of the damaged wire on autopilot operation.

Figure 1: Damaged wire within the autopilot controller

Figure 1: Damaged wire within the autopilot controller

The ongoing investigation will include examination of:

  • the aircraft's autopilot and electric pitch trim systems
  • the inspection requirements for wiring to critical systems
  • the degree of autopilot system training provided during aircraft endorsement training.

  1. CAVOK is defined as visibility of 10km or more, no cloud below 5,000 ft or below the highest minimum sector altitude whichever is greater, no cumulonimbus clouds and no precipitation, thunderstorm, shallow fog, low drifting snow or dust devils.
General details
Date: 07 March 2005   Investigation status: Completed  
Time: 1329 hours ESuT    
Location   (show map): 7 km WSW Tamworth, Aero.    
State: New South Wales   Occurrence type: Collision with terrain  
Release date: 21 June 2007   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 310  
Aircraft registration VH-FIN  
Serial number 310R0903  
Type of operation Private  
Damage to aircraft Destroyed  
Departure point Tamworth, NSW  
Departure time 1326 hours ESuT  
Destination Scone, NSW  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command Commercial 58.1 1005.5
  Crew Passenger Ground Total
Fatal: 1 0 0 1
Total: 1 0 0 1
Last update 16 February 2016