Aviation safety investigations & reports

Collision with water involving Grumman American Aviation Corp G-73, VH-CQA, 10 km WSW of Perth Airport, Western Australia on 26 January 2017

Investigation number:
AO-2017-013
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 26 January 2017, the pilot of a Grumman American Aviation Corp G-73 amphibian aircraft, registered VH‑CQA (CQA), was participating in an air display as part of the City of Perth Australia Day Skyworks event. On board were the pilot and a passenger. The pilot of CQA was flying ‘in company’ with a Cessna Caravan amphibian and was conducting operations over Perth Water on the Swan River, that included low-level passes of the Langley Park foreshore.

After conducting two passes in company, both aircraft departed the display area. The pilot of CQA subsequently requested and received approval to conduct a third pass, and returned to the display area without the Cessna Caravan. During positioning for the third pass, the aircraft departed controlled flight and collided with the water. The pilot and passenger were fatally injured.

What the ATSB found

The ATSB found that the aircraft aerodynamically stalled during a positioning turn for the third pass, resulting in the collision with shallow water. The manner in which the pilot returned to the display area after the second pass was not in accordance with the display procedures and increased the risk of mishandling the aircraft in an area of relatively close proximity to the public. The pilot’s decision to carry a passenger was also contrary to the requirements of the display instrument and increased the severity of the outcome.

Finally, a safety issue was identified with the current regulatory framework for air display approval and oversight.

What's been done as a result

The Civil Aviation Safety Authority had independently published a revised manual of guidance for air displays in September 2017. The document provided further detail on the key roles and their responsibilities and introduced a requirement to conduct a risk assessment as part of the application process. In April 2018, CASA updated the associated participant form, which was expanded to assist pilots with their display preparation and included a requirement to identify and provide justification for any additional persons on board display aircraft. The form also included a section to provide additional assurance around completion of the display coordinator’s responsibilities.

Finally, the ATSB has issued a safety recommendation to CASA to undertake further work to enhance their tools and guidance for air display approval and oversight, and procedures to ensure the suitability of those responsible for organising, coordinating and participating in air displays.

Safety message

Air displays are activities with inherent and unique risks that pilots, the organisers and the regulators all have responsibilities in addressing. It is important that holders of these key positions have a thorough understanding of their role and responsibilities, to ensure adequate completion of safety critical tasks. Having well-defined, transparent and consistent processes for planning and approval of air displays will assist in identifying risks and implementing effective mitigation strategies.

In addition to complying with regulations, pilots can limit their risk exposure by only participating in displays that are within their own and their aircraft’s capabilities and limitations, and not undertake any impromptu manoeuvres that have not been planned or practiced.

These steps combined will provide greater safety assurance for participants, spectators and the general public.

VH-CQA

Grumman American Aviation Corp G-73, VH-CQA. Source:  Flightaware.com

Source:  Flightaware.com

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

General details

Sources and submissions

Preliminary report

Preliminary report

Published: 22 September 2017

On 26 January 2017, the pilot of a Grumman American Aviation Corp G-73 amphibian aircraft, registered VH‑CQA (CQA), was participating in an air display as part of the City of Perth Australia Day Skyworks event. On board were the pilot and a passenger. The weather was fine with a recorded wind of about 20 km/hr from the south-west and a temperature of about 39 °C.

The pilot of CQA was flying ‘in company’ with a Cessna Caravan amphibian and conducted a series of circuits that included low-level fly-pasts of the Langley Park foreshore (Figure 1). After the second fly-past, the pilot of CQA commenced a third circuit, while the Caravan departed the area.

Figure 1: CQA air display flight track, showing the first fly-past in yellow, the second in magenta and the third in red

Figure 1: CQA air display flight track, showing the first fly-past in yellow, the second in magenta and the third in red

Source: OzRunways Pty. Ltd., modified by the ATSB

As part of the third circuit, the pilot of CQA flew in an easterly direction, parallel with the South Perth foreshore, before commencing a left turn. This would have facilitated a third pass in a westerly direction along the Langley Park foreshore. During the left turn, CQA rolled left and pitched nose down, consistent with an aerodynamic stall[1] (Figure 2). The aircraft collided with the water and broke up. The pilot and passenger were fatally injured.

Figure 2: CQA just prior to the collision with water (looking north)

Figure 2: CQA just prior to the collision with water (looking north)

Source: Mike Graham

The ATSB completed the on-site phase of its investigation on 4 February 2017. No pre-existing aircraft defects, which may have contributed to the collision with water, were identified. The ATSB has retained several items and components from the aircraft for further examination. This includes a fuel totaliser, a navigation unit and a mobile phone.

The investigation is continuing and will include:

  • examination of numerous witness reports and images and a significant quantity of video footage taken on the day by members of the public, media outlets and so on
  • review of the aircraft’s maintenance records, operational records for recent flights and pilot training records
  • review of the meteorological conditions at the time
  • an examination of aircraft performance and other operational factors
  • further examination of the recorded flight radar, radio and Global Positioning System data
  • review of the planning, approval and oversight of the air display, including a focus on safety and risk management practices.

Should any critical safety issues emerge during the course of the investigation, the ATSB will immediately bring those issues to the attention of the relevant authorities or organisations. This will allow those authorities and organisations to consider safety action to address the safety issues. Details of such safety issues and any safety action in response will be published on the ATSB website at www.atsb.gov.au.

Since the release of its preliminary report on 8 March 2017, the ATSB has provided an update to this investigation.

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The information contained in this web 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.

 

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  1. Aerodynamic stall: occurs when the airflow separates from the wing’s upper surface and becomes turbulent. A stall occurs at high angles of attack, typically 16˚ to 18˚, and results in reduced lift.

Safety Issue

Go to AO-2017-013-SI-01 -

Air display approval and oversight

The Civil Aviation Safety Authority (CASA) did not have an effective framework to approve and oversight air displays, predominantly due to the following factors:

  • While the Air Display Manual provided guidance to organisers conducting an air display, it did not inherently provide the processes and tools needed for CASA to approve and oversee one and no other documented guidance existed.
  • Unlike the accreditation models adopted by some other countries, CASA did not have a systematic approach for assessing the suitability of those responsible for organising, coordinating and participating in air displays.
  • CASA did not have a structured process to ensure that risks were both identified and adequately treated.

The combination of these factors significantly increased the likelihood that safety risks associated with the conduct of the air display were not adequately managed.

Safety issue details
Issue number: AO-2017-013-SI-01
Who it affects: Air displays: Organisers and participants in air displays
Status: Safety action pending
General details
Date: 26 January 2017   Investigation status: Completed  
Time: 1708 WST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Swan River, Perth   Investigation phase: Final report: Dissemination  
State: Western Australia   Occurrence type: Loss of control  
Release date: 19 November 2019   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Grumman American Aviation Corp  
Aircraft model G-73 Mallard (amphibious)  
Aircraft registration VH-CQA  
Serial number J-35  
Operator Private  
Type of operation Aerial Work  
Damage to aircraft Destroyed  
Last update 19 November 2019