Aviation safety investigations & reports

Loss of control involving Cessna Aircraft Company U206G, VH-FRT, Caboolture Airfield, Queensland, on 22 March 2014

Investigation number:
AO-2014-053
Status: Completed
Investigation completed

Final Report

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What happened

On 22 March 2014, a Cessna Aircraft Company (Cessna) U206G aircraft, registered VH-FRT, was being used for tandem parachuting operations at Caboolture Airfield, Queensland. At about 1124 Eastern Standard Time, the aircraft took off from runway 06 with the pilot, two parachuting instructors and two tandem parachutists on board. Shortly after take-off, witnesses at the airfield observed the aircraft climb to about 200 ft above ground level before it commenced a roll to the left. The left roll steepened and the aircraft then adopted a nose‑down attitude until impacting the ground in an almost vertical, left-wing low attitude. All of the occupants on board were fatally injured. A post-impact, fuel-fed fire destroyed the aircraft.

What the ATSB found

The ATSB identified that the aircraft aerodynamically stalled at a height from which it was too low to recover control prior to collision with terrain. The reason for the aerodynamic stall was unable to be determined. Extensive fire damage prevented examination and testing of most of the aircraft components. Consequently, a mechanical defect could not be ruled out as a contributor to the accident.

A number of safety issues were also identified by the ATSB. These included findings associated with occupant restraint, modification of parachuting aircraft and the regulatory classification of parachuting operations.

What's been done as a result

The Australian Parachute Federation (APF) mandated a requirement for all member parachute training/tandem organisations to have their own safety management system. The APF have also increased the number of full‑time safety personnel to audit their member organisations.

The Civil Aviation Safety Authority (CASA) has increased the available information on their website about the risks associated with sports aviation. CASA also introduced an Airworthiness Bulletin to provide guidance about co‑pilot side flight control modifications.

In response to the identified safety issues, the ATSB has recommended that CASA take safety action to increase the fitment of the Cessna secondary pilot seat stop modification and reduce the risk associated with the aviation aspect of parachuting operations. Finally, recommendations were issued to CASA and the APF to increase the use of dual‑point restraints in parachuting aircraft.

Safety message

The current classification of parachuting as a private operation means there are fewer risk controls than for other similar aviation activities that also involve payment for carriage. Prospective tandem parachutists should be aware that accident data indicates that parachuting is less safe than other aviation activities, such as scenic flights.

The ATSB’s investigation of this accident, and a previous fatal parachuting accident, indicated that the single-point restraints currently fitted to Australian parachuting aircraft may not be consistently used by occupants. While research shows that they may not be as effective as dual-point restraints at preventing injury in an accident, they do limit the movement of parachutists within the aircraft, therefore reducing the likelihood of load shift during flight. That affords some occupant protection and ensures that the aircraft remains controllable.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Appendices

Recommendations

Secondary seat stop modification not mandatory

Despite being categorised as mandatory for the pilot’s seat by the aircraft manufacturer, a secondary seat stop modification designed to prevent uncommanded rearward pilot seat movement and potential loss of control was not fitted to VH-FRT, nor was it required to be under United States or Australian regulations.

Safety Recommendation AO-2014-053-SR-017

The ATSB recommends that the Civil Aviation Safety Authority takes action to strengthen incorporation of Cessna Single Engine Service Bulletin SEB07-5 Secondary seat stop modification.

Dual-point restraints

Research has identified that rear‑facing occupants of parachuting aircraft have a higher chance of survival when secured by dual-point restraints, rather than the standard single-point restraints that were generally fitted to Australian parachuting aircraft.

Safety Recommendation AO-2014-053-SR-018

Safety Recommendation AO-2014-053-SR-019

The ATSB recommends that the Australian Parachute Federation, in conjunction with the Civil Aviation Safety Authority, takes action to increase the usage of dual point restraints in parachuting aircraft that are configured for rear facing occupants.

Classification of parachuting operations

Classification of parachuting operations in the private category did not provide comparable risk controls to other similar aviation activities that involve the carriage of the general public for payment.

Safety Recommendation AO-2014-053-SR-020

The ATSB recommends that the Civil Aviation Safety Authority introduce risk controls to parachuting operations that provide increased assurance of aircraft serviceability, pilot competence and adequate regulatory oversight.

 

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Safety Issues

Go to AO-2014-053-SI-01 - Go to AO-2014-053-SI-02 - Go to AO-2014-053-SI-03 - Go to AO-2014-053-SI-04 - Go to AO-2014-053-SI-05 -

Secondary seat stop modification not mandatory

Despite being categorised as mandatory for the pilot’s seat by the aircraft manufacturer, a secondary seat stop modification designed to prevent uncommanded rearward pilot seat movement and potential loss of control was not fitted to VH-FRT, nor was it required to be under United States or Australian regulations.

Safety issue details
Issue number: AO-2014-053-SI-01
Who it affects: Single engine Cessna aircraft operators
Status: Closed – Adequately addressed

Unapproved aircraft flight control modifications

Some Cessna 206 parachuting aircraft, including VH-FRT, had their flight control systems modified without an appropriate maintenance procedure or approval. That increased the risk of flight control obstruction.

Safety issue details
Issue number: AO-2014-053-SI-02
Who it affects: Parachute jump operators
Status: Closed – Adequately addressed

Dual-point restraints

Research has identified that rear‑facing occupants of parachuting aircraft have a higher chance of survival when secured by dual-point restraints, rather than the standard single-point restraints that were generally fitted to Australian parachuting aircraft.

Safety issue details
Issue number: AO-2014-053-SI-03
Who it affects: Parachute aircraft owners
Status: Closed – Not addressed

Restraint use in parachuting aircraft

It was likely that the parachutists on the accident flight, as well as those that had participated in previous flights, were not secured to the single-point restraints that were fitted to VH-FRT. While research indicates that single-point restraints provide limited protection when compared to dual-point restraints, they do reduce the risk of load shift following an in-flight upset, which can lead to aircraft controllability issues.

Safety issue details
Issue number: AO-2014-053-SI-04
Who it affects: Australian parachuting industry
Status: No longer relevant

Classification of parachuting operations

Classification of parachuting operations in the private category did not provide comparable risk controls to other similar aviation activities that involve the carriage of the general public for payment.

Safety issue details
Issue number: AO-2014-053-SI-05
Who it affects: Australian parachuting industry
Status: Closed – Partially addressed
General details
Date: 22 March 2014   Investigation status: Completed  
Time: 1124 EST   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Caboolture Airfield    
State: Queensland   Occurrence type: Terrain Collision  
Release date: 23 June 2017   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model U206G  
Aircraft registration VH-FRT  
Serial number U20604019  
Type of operation Private  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Caboolture Airfield, Queensland  
Destination Caboolture Airfield, Queensland  
Last update 06 November 2020