Aviation safety investigations & reports

Collision with terrain following an engine power loss involving Cessna 172M, VH‑WTQ, 12 NM (22 km) north-west of Agnes Water, Queensland on 10 January 2017

Investigation number:
AO-2017-005
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 10 January 2017, at about 1030 Eastern Standard Time, a Cessna 172M, registered VH‑WTQ, departed Agnes Water aeroplane landing area (ALA), Queensland on a passenger charter flight to a beach ALA on Middle Island. There was a pilot and three passengers on board.

At about 1038, the pilot was conducting an airborne inspection of the beach ALA to ensure that it was suitable for a landing. During the inspection, when the aircraft was at about 60 ft above mean sea level (AMSL), the aircraft’s engine had a sudden and total power loss.

After conducting initial checks, the pilot elected to conduct a significant left turn to the beach. During the continued turn, the aircraft impacted the beach with little or no control and a significant descent rate. One of the rear-seat passengers was fatally injured and the other three occupants sustained serious injuries. The aircraft was destroyed.

What the ATSB found

Despite a detailed inspection of the engine and related systems, the ATSB was unable to identify the reason for the loss of engine power. Nevertheless, the ATSB found that the operator’s procedures and practices for conducting airborne inspections of the Middle Island ALA did not effectively manage the risk of an engine failure or power loss when at a low height. The inspections were generally flown at 50–100 ft AMSL while flying at normal cruise speed towards an area of water at the end of the beach, with no planned consideration of what to do in the event of an emergency.

Although not found to be contributing to the accident, there were a number of other problems identified with the operator’s activities. The documented flight hours for the aircraft underestimated the actual flight hours. In addition, for the accident flight, the aircraft exceeded the maximum take-off weight and the baggage and supplies on the aircraft were not effectively secured. The ATSB also identified safety issues with the operator’s practices for calculating weight and balance, securing loads, and the conduct of near-aerobatic manoeuvres during passenger charter flights with limited controls in place to manage the risk of such manoeuvres. More generally, the operator had no effective assurance mechanisms in place to regularly and independently review the suitability of its activities.

The aircraft’s rear seats were not equipped with upper torso restraints (shoulder belts or harnesses). Such restraints were not required for seats (other than in the front row) of small aeroplanes manufactured prior to December 1986, however, numerous international investigation agencies (including the ATSB) and some aircraft manufacturers have recommended they be fitted. Had such restraints been fitted, the rear-seat passengers’ injuries would very likely have been less severe.

Although the operator’s primary activity since July 2009 was passenger transport flights to beach aeroplane landing areas (ALAs), regulatory oversight by the Civil Aviation Safety Authority (CASA) had not examined the operator’s procedures and practices for conducting flight operations at these ALAs. It was difficult to determine whether additional focus on this topic during surveillance would have identified the problems associated with the operator’s airborne inspections. Nevertheless, the ATSB identified a safety issue with CASA’s procedures and guidance for scoping surveillance events.

What's been done as a result

Following the accident, CASA requested the operator to cease flight operations under its Air Operator’s Certificate (AOC). On 27 January 2017, CASA issued the operator with a notice of immediate suspension of its AOC, and on 10 March 2017 the operator requested that CASA cancel its AOC.

CASA has stated that it will not be mandating the fitment of upper torso restraints, even for air transport flights in small aircraft. Given that a significant number of small aircraft in Australia still do not have upper torso restraints in non-front row seats, the ATSB has issued a safety recommendation to CASA. The ATSB recommends that CASA consider mandating the fitment of upper torso restraints for all seats in small aircraft, particularly those used for air transport operations and/or aircraft where the manufacturer has issued a mandatory service bulletin to fit upper torso restraints for all seats.

While this is being considered by CASA, the ATSB has issued a safety advisory notice to encourage all owners and operators of small aircraft to fit upper torso restraints for all passenger seats to minimise injury risk.

CASA has also advised that air transport operators of small aeroplanes will be required to brief passengers about when and how to adopt a brace position.

Finally, the ATSB has issued a safety recommendation to CASA to improve its procedures and guidance for scoping surveillance events.

Safety message

This accident reinforces standard pilot training and guidance that, following an engine power loss at a low height, an emergency landing should (in most cases) be planned straight ahead with only small changes in direction to avoid obstructions. Operators and pilots should review their flight procedures to ensure that such emergency landings are possible when their aircraft are at a low height. If such landings are not possible, or the lowest risk option available, then the suitability of the flight activity should be evaluated.

Operators and pilots that conduct airborne inspections of landing areas should also ensure that the risk of an engine failure or power loss is considered when planning and conducting such inspections at a low height, particularly when below 500 ft.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

General details

Sources and submissions

Appendices

Australian Transport Safety Bureau

Initial summary

Updated: 13 January 2017

ATSB investigators have completed the on-site phase of the investigation into the collision with terrain involving Cessna C172M, registered VH-WTQ, near Agnes Water, Queensland on 10 January 2017.

As part of the ongoing investigation, the ATSB will continue to gather further evidence, including:

  • pilot and aircraft maintenance documentation
  • additional witness statements
  • recovery and examination of relevant data.

Further updates will be provided as significant information comes to hand.

 

 

Published: 10 January 2017

The ATSB is investigating a fatal accident involving a Cessna 172M near Agnes Water, Queensland on 10 January 2017. It is reported the aircraft collided with terrain and came to rest inverted, resulting in substantial damage. One person was fatally injured and three others sustained serious injuries.

The ATSB has deployed two investigators—specialising in aircraft engineering and operations—to the accident site. While on site, the investigators will survey the site, examine the wreckage, talk to witnesses and review aircraft and pilot documentation. They are expected to be onsite for three days.

Witnesses are asked to call the ATSB on 1800 020 616.

Preliminary report

Published: 1 March 2017

History of the flight

On 10 January 2017, at about 1030 Eastern Standard Time,[1] a Cessna Aircraft Company 172M, registered VH-WTQ (WTQ), departed Agnes Water Airstrip on a charter service to a beach‑landing location about 12 NM (22 km) to the north-west near Middle Island, Queensland. On board were a pilot and three passengers (Figure 1).

The pilot reported that at about 1038, while conducting a low-altitude inspection of the beach‑landing site, the aircraft sustained a sudden loss of engine power. With limited time to respond to the power loss, and in an effort to avoid landing in the water, the pilot elected to turn back and land on the beach. The pilot reported considering this the safest option.

Figure 1: WTQ flight track and accident location with an indication of the general area at inset

VH-WTQ flight track and accident location with an indication of the general area at inset

Source: Google earth, modified by the ATSB

Two witnesses who observed the accident sequence indicated that the aircraft was flying parallel to the beach before turning left at an increasingly steep bank angle. The left wingtip struck the ground and then the nose, before the aircraft came to rest about 5 m past the nose impact point. One of the rear-seat passengers was fatally injured and the other three occupants sustained serious injuries. The aircraft was destroyed (Figure 2).

The pilot of another aircraft that was also operating a charter service to the same location, and was about 2 NM (4 km) behind WTQ, reported not seeing the accident sequence. When the pilot of the other aircraft observed the wreckage of WTQ during a flypast of the accident site, they immediately radioed air traffic services to advise that there had been an accident. The pilot landed the aircraft on the beach and, in conjunction with witnesses already at the scene, provided emergency assistance.

Figure 2: WTQ wreckage and accident site looking north-east

VH-WTQ wreckage and accident site looking north-east

Source: ATSB

Site and wreckage

Inspection of the site and wreckage identified:

  • that the aircraft impacted terrain in a left wing-low, steep nose-down attitude
  • that the aircraft was facing the opposite direction to the initial impact
  • no sign of rotational damage to the propeller
  • all of the aircraft components and flight control surfaces
  • continuity of the flight control systems
  • that the flaps were in the ‘up’ position when the aircraft impacted the ground.

Several aircraft components, including the engine and a Garmin 296 Global Positioning System (GPS) unit, were removed from the accident site for further examination by the ATSB.

Recorded information

GPS data

Data from the recovered GPS unit was successfully downloaded by the ATSB. This data included recorded values of time, latitude, longitude and altitude about every 10 seconds throughout the accident flight. Using the data, the aircraft’s flight path from Agnes Water to the accident site was overlayed on Google earth (Figure 3).

Figure 3: WTQ GPS-derived flight path, represented by red lines. The red lines are direct connections between each 10-second recording point and do not represent the aircraft’s actual flight path between points. Note that the image shows the local area at about low tide, whereas there was an outgoing high tide at the time of the accident

VH-WTQ GPS-derived flight path, represented by red lines.

Source: Google earth, modified by the ATSB

Radar data

A review of the Airservices Australia recorded radar data showed a number of secondary radar returns[2] that were confirmed to be from WTQ. The radar data provided track and altitude information from 1032 until 1038, at which time the radar return was lost.

Video footage

The Queensland Police Service downloaded data from a mobile phone that was located on the accident site. This data was provided to the ATSB and included a video file of the entire flight and accident sequence. The video was taken by the passenger who occupied the front-right seat.

Recovered flight video

Preliminary analysis of the recovered flight video indicated:

  • a normal take-off and climb to a cruise altitude of about 1,500 ft
  • at about 4 minutes flight time, the pilot conducted a series of manoeuvres including steep turns, steep climbs and descents, manoeuvres that were consistent with negative g[3] and yawing[4] the aircraft left and right
  • after about 6 minutes flight time, and after a second series of yawing and other manoeuvres that were consistent with negative g, the engine power momentarily reduced before recovering
  • a descent down to about 100 ft and flight parallel to the beach over water, consistent with the conduct of a beach-landing site inspection
  • at about 7 minutes flight time, the engine sustained a sudden power loss and subsequently the:
    • pilot turned the aircraft to the right momentarily before raising the nose and initiating a left turn with an initial bank angle of about 45°
    • bank angle increased and the airspeed decreased to a point where the aircraft’s stall warning horn sounded for about 3 seconds
    • aircraft rolled left and pitched nose down before impacting terrain.

Pilot actions following engine power loss

The circumstances of this accident are still being investigated. However, the ATSB reminds pilots that the risk of injury following a complete or partial engine power loss can be significantly reduced by using strategies such as:

  • undertaking pre-flight decision making and planning for emergencies and abnormal situations for a particular landing area
  • taking positive action and maintaining aircraft control, either when turning back to the landing area or conducting a forced landing, while being aware of the variables affecting the success of the forced landing such as any flare energy and the aircraft’s height and stall speed.

Continuing investigation

The investigation is continuing and will include examination of the:

  • GPS, video and radar data
  • recovered engine and engine components
  • pilot information
  • aircraft, operator, and maintenance documentation and procedures
  • aircraft weight and balance.


_____________

The information contained in this update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.

 

__________

  1. Eastern Standard Time (EST): Coordinated Universal Time (UTC) + 10 hours.
  2. Secondary surveillance radar relies on an aircraft’s operational transponder transmitting a data signal in response to being interrogated by an air traffic service radar or another receiver (for example, another aircraft’s Traffic Alert and Collision Avoidance System). The amount of information transmitted in the data signal is dependent on the type of transponder in the aircraft. This can range from the aircraft’s altitude (Mode C) to the identification of the flight and the pilotselected cruising level (Mode S).
  3. G load: the nominal value for acceleration. In flight, g load represents the combined effects of flight manoeuvring loads and turbulence and can have a positive or negative value.
  4. Yawing: the motion of an aircraft about its vertical or normal axis.

Safety Issues

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Operator’s procedures and practices for airborne inspections of a landing area

The operator normally conducted airborne inspections of the Middle Island aeroplane landing area at about 50–100 ft while flying at normal cruise speed towards an area of water, and its procedures did not ensure the effective management of the risk of an engine failure or power loss when at a low height.

Safety issue details
Issue number: AO-2017-005-SI-01
Who it affects: The operator’s pilots and passengers.
Status: No longer relevant

Operator’s aircraft loading practices

Although the operator’s procedures required that actual weights be used for passengers, baggage and other cargo, this procedure was routinely not followed, and pilots relied on estimated weights when calculating an aircraft’s weight and balance.

Safety issue details
Issue number: AO-2017-005-SI-02
Who it affects: The operator’s pilots and passengers.
Status: No longer relevant

Operator’s practices for securing baggage and other cargo

Although the operator’s procedures required that baggage and cargo be secured during flight, this procedure was routinely not followed, and the aircraft were not equipped with cargo nets or other means for securing loads in the baggage compartment.

Safety issue details
Issue number: AO-2017-005-SI-03
Who it affects: The operator’s pilots and passengers.
Status: No longer relevant

Operator’s conduct of near-aerobatic manoeuvres during charter flights

The operator’s pilots routinely conducted near-aerobatic manoeuvres during passenger charter flights. However, procedures for these manoeuvres were not specified in the operator’s Operations Manual, and there were limited controls in place to manage the risk of these manoeuvres.

Safety issue details
Issue number: AO-2017-005-SI-04
Who it affects: The operator’s pilots and passengers.
Status: No longer relevant

Operator’s processes for reviewing its operations

There were a significant number and variety of problems associated with the operator’s activities that increased safety risk, and the operator’s chief pilot held all the key positions within the operator’s organisation and conducted most of the operator’s flights. Overall, there were no effective mechanisms in place to regularly and independently review the suitability of the operator’s activities, which enabled flight operations to deviate from relevant standards.

Safety issue details
Issue number: AO-2017-005-SI-05
Who it affects: The operator’s pilots and passengers.
Status: No longer relevant

Requirements for upper torso restraints in small aircraft

Upper torso restraints (UTRs) were not required for all passenger seats for small aeroplanes manufactured before December 1986 and helicopters manufactured before September 1992, including for passenger transport operations. Although options for retrofitting UTRs are available for many models of small aircraft, many of these aircraft manufactured before the applicable dates that are being used for passenger transport have not yet been retrofitted.

Safety issue details
Issue number: AO-2017-005-SI-06
Who it affects: All aircraft owners, operators, pilots and passengers of small aircraft without upper torso restraints for all passenger seats.
Status: Safety action pending

Requirements for briefing the brace position in small aircraft

There was no requirement for operators of passenger transport flights in aircraft with six or less seats to provide passengers with a verbal briefing, or written briefing material, on the brace position for an emergency landing or ditching, even for aircraft without upper torso restraints fitted to all passenger seats.

Safety issue details
Issue number: AO-2017-005-SI-07
Who it affects: All aircraft owners, operators, pilots and passengers of small aeroplanes.
Status: Safety action pending

Regulatory surveillance – scoping of surveillance events

The Civil Aviation Safety Authority’s procedures and guidance for scoping a surveillance event included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

Safety issue details
Issue number: AO-2017-005-SI-08
Who it affects: All operators.
Status: Safety action pending
General details
Date: 10 January 2017   Investigation status: Completed  
Time: 1038 EST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): 22 km north-west of Agnes Water   Investigation phase: Final report: Dissemination  
State: Queensland   Occurrence type: Collision with terrain  
Release date: 17 October 2019   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 172M  
Aircraft registration VH-WTQ  
Serial number 17261931  
Type of operation Charter  
Sector Piston  
Damage to aircraft Substantial  
Departure point Agnes Water  
Last update 17 October 2019