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Updated: 27 June 2018

The investigation into the fatal collision with terrain near Mount Gambier in June 2017 is continuing.

ATSB investigators have examined the aircraft components recovered from the accident site and pilot transmissions from the common traffic advisory frequency for Mount Gambier Airport as well as GPS data and CCTV footage from the airport.

Investigators have also reviewed the aircraft’s maintenance documentation, pilot qualifications and experience,  and pre-flight planning as well as the weather conditions at the time of the accident.

In addition to a review of other similar accidents, investigators are currently reviewing all existing aviation safety data related to community service flights - for non-emergency medical purposes by voluntary or charitable organisations.

This involves a review of all available safety information from the ATSB aviation occurrence database and information on flight planning, coordination and oversight from the voluntary and charitable organisation.

Information from this review, along with other data from the investigation, is currently being analysed.

A final report will be released at the end of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.

 

Published: 1 August 2017

At about 0800 Central Standard Time[1] on 28 June 2017, a SOCATA TB-10 aircraft, registered VH-YTM (YTM), departed Murray Bridge Airport for Mount Gambier Airport, South Australia.

Position and altitude information obtained from OzRunways[2] showed that the aircraft’s inbound path (Figure 1) from Murray Bridge was straight and at an altitude of about 4,500 ft. At about 42 km north-north-west of Mount Gambier Airport, the altitude decreased and there was a significant deviation from the direct route. Several manoeuvres were then made at low altitude in the vicinity of the airport, including a possible attempted landing on runway 36. After a series of low level turns, the aircraft landed on runway 29 at about 1008.

Figure 1: Approach path of VH-YTM showing the initial deviations from the direct flight path on the left, and the series of low level turns prior to landing on runway 29 on the right

Figure 1: Approach path of VH-YTM showing the initial deviations from the direct flight path on the left, and the series of low level turns prior to landing on runway 29 on the rightSource: Google Earth and OzRunways, annotated by ATSB

The pilot then refuelled the aircraft and boarded two passengers, to conduct a flight to Adelaide arranged by the charity Angel Flight Australia.[3] The flight was to be conducted as a private flight under visual flight rules (VFR).

Witnesses in the vicinity of Mount Gambier Airport reported fog in the area at the time of landing and take-off. Similarly, CCTV footage showed the fog and reduced visibility conditions at the airport at the time of landing and take-off.

OzRunways data (Figure 2) and CCTV footage showed the aircraft took off from runway 24 at about 1020. Just after take-off, YTM veered to the left of the runway, at an altitude of approximately 300 ft above mean sea level (AMSL). The aircraft reached a maximum altitude of about 500 ft, 45 seconds after take-off. The last recorded information, about 65 seconds after take-off, showed the aircraft at an altitude of 400 ft.

A number of witnesses heard a loud bang, consistent with the aircraft’s impact with terrain.

Figure 2: Flight path of VH-YTM after departing runway 24 at Mount Gambier Airport, where each vertical line represents 5 seconds, and an indication of the wreckage location

Figure 2: Flight path of VH-YTM after departing runway 24 at Mount Gambier Airport, where each vertical line represents 5 seconds, and an indication of the wreckage locationSource: Google Earth and OzRunways, annotated by ATSB

Transmissions from the pilot of YTM on approach and take-off were recorded on the common traffic advisory frequency for Mount Gambier Airport. However, no emergency call was recorded. The aircraft was not equipped with a flight data recorder or cockpit voice recorder, nor was it required.

Minutes after impact the aircraft was found by witnesses passing the accident site, and emergency services responded to the scene shortly thereafter. The aircraft wreckage was located 212 m south of the last recorded position, just over 2 km from the departure runway (Figure 2). The pilot and two passengers were fatally injured and the aircraft destroyed.

On-site examination of the wreckage and surrounding ground markings (Figure 3) indicated that the aircraft impacted terrain at approximately 30° from vertical, in an inverted attitude. The engine and propeller were located at the initial impact point. The fuselage and remainder of the aircraft had detached from the engine at the firewall, and came to rest in an upright position about 10 m beyond the engine, with the tail and wings attached. The wings had sustained significant impact damage to the leading edge. A strong smell and presence of fuel was evident at the accident site, however there was no evidence of fire. The aircraft did not have an emergency locator transmitter fitted, nor was it required. A portable locator beacon was found in the cockpit, but had not been activated.

Figure 3: Accident site looking north-west, showing the engine and propeller location alongside the left and right wing impact marks, about 10 m from the main wreckage, which is upright and facing in a north-north-easterly direction

Figure 3: Accident site looking north-west, showing the engine and propeller location alongside the left and right wing impact marks, about 10 m from the main wreckage, which is upright and facing in a north-north-easterly directionSource: ATSB

Several components and documentation were removed from the accident site for further examination by the ATSB.

The investigation is continuing and will include examination of the following:

  • recovered components and available electronic data
  • aircraft maintenance documentation
  • weather conditions
  • pilot qualifications and experience
  • coordination and planning of the charity flight
  • the use of private flights for the transfer of passengers for non-emergency medical reasons
  • similar occurrences.

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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. Central Standard Time (CST) was Co-ordinated Universal Time (UTC) +9.5 hours.
  2. OzRunways is an electronic flight bag application that provides navigation, weather, area briefings and other flight planning information.
  3. Angel Flight Australia is a charity that coordinates non-emergency flights to assist people to access specialist medical treatment.
 

The ATSB is investigating a fatal aircraft accident involving a SOCATA TB-10 Tobago aircraft, registered VH-YTM, that occurred about 3km south-west of Mount Gambier Airport, South Australia on 28 June 2017.

The aircraft collided with terrain. The pilot and two passengers were fatally injured.

The ATSB has deployed a team of four investigators to the accident site with expertise that includes aircraft engineering, technical and human factors.

While on site the team will be examining the site and wreckage, gathering any recorded data, and interviewing any witnesses.

The ATSB will provide an update on its website outlining the facts of the accident within 30 days.

 
General details
Date: 28 June 2017 Investigation status: Active 
Time: 10:30 CST Investigation phase: Examination and analysis 
Location   (show map):3 km south-west of Mount Gambier Airport Investigation type: Occurrence Investigation 
State: South Australia Occurrence type: Collision with terrain 
Release date: 25 July 2017 Occurrence class: Operational 
Report status: Preliminary Occurrence category: Accident 
Anticipated completion: 4th Quarter 2018 Highest injury level: Fatal 
 
Aircraft details
Aircraft manufacturer: S.O.C.A.T.A.-Groupe Aerospatiale 
Aircraft model: TB-10 
Aircraft registration: VH-YTM 
Serial number: 1518 
Type of operation: Private 
Sector: Piston 
Damage to aircraft: Substantial 
Departure point:Mt Gambier, South Australia
Destination:Adelaide, South Australia
 
 
 
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Last update 11 July 2018