Aviation safety investigations & reports

Engine shutdown and collision with terrain involving Beech Aircraft Corporation B200, VH-MVL Moomba Airport, South Australia, 13 December 2016

Investigation number:
AO-2016-170
Status: Completed
Investigation completed

Final Report

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What happened

On 13 December 2016, a Beech Aircraft Corporation B200, registered VH-MVL, conducted a visual approach to Moomba Airport, South Australia (SA), following a medical services flight from Innamincka, SA. As the aircraft turned onto the base leg of the approach, the pilot observed the left engine fire warning activate. The pilot shut down the left engine and continued the approach to the runway. The aircraft landed in the sand to the left of the runway threshold and after a short ground roll, spun to the left and came to rest. There were no injuries and the aircraft was substantially damaged.

What the ATSB found

The ATSB found that the pilot did not feather the left propeller (rotate the blades to an edge-on angle to the airflow) after the left engine was shut down, causing it to windmill, resulting in considerable drag. In addition, the aircraft was in a right turn, towards the engine developing power, with the landing gear extended and the flaps set to approach. This combination resulted in more thrust being required for continued safe flight than was available.

No engine fire damage was found and it was therefore concluded that the observed fire warning was almost certainly a false warning. The aircraft manufacturer had previously published a service bulletin for the optional replacement of the engine fire detection system with a system less susceptible to false warnings. However, the operator, who had limited experienced with false engine warnings in their fleet which were also considered as low risk, elected not to replace the fire detection system on the accident aircraft.

The accident pilot did not receive the operator’s published syllabus of training for the B200 King Air. Instead, a tailored training program was delivered in consideration of the pilot’s experience on the C90 King Air with another operator and advice the operator received from the Civil Aviation Safety Authority. This training did not cover all the elements required under the Civil Aviation Safety Regulations.

What's been done as a result

As a result of this occurrence, the Civil Aviation Safety Authority (CASA) intends to take steps to refresh industry and CASA officers’ knowledge of particular terms and concepts within the flight crew licencing regulations to remove any doubt that might exist as to their interpretation and applicability.

The operator has undertaken to take safety actions in the areas of pilot recruitment, training and checking, aircraft and systems, safety and quality assurance, and communications.

Safety message

Following the accident, the pilot reported that their biggest lesson was not to hesitate during emergency procedures. They believed that their doubt in the veracity of the warning resulted in their hesitation while completing the four engine fire drill (memory) actions, resulting in them missing the step to feather the propeller.

This accident also highlights the need for organisations to consider all the relevant information available to them when making decisions, such as the process for reviewing non‑mandatory service bulletins. Organisational decision-making should consider the potential consequences of human error when evaluating changes.

 

Download Final Report
[Download  PDF: 1.35MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Photo

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General details
Date: 13 December 2016   Investigation status: Completed  
Time: 12:55 CSuT   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Moomba Aerodrome    
State: South Australia   Occurrence type: Collision with terrain  
Release date: 06 July 2017   Occurrence class: Operational  
Report status: Final   Occurrence category: Accident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Beech Aircraft Corp  
Aircraft model B200  
Aircraft registration VH-MVL  
Serial number BB-1333  
Type of operation Aerial Work  
Sector Turboprop  
Damage to aircraft Substantial  
Departure point Innamincka, SA  
Destination Moomba, SA  
Last update 14 November 2018