Aviation safety investigations & reports

In-flight break-up involving Cessna 210B, VH-DBU, 30 km NW of Albany, Western Australia, on 24 October 2017

Investigation number:
AO-2017-103
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 24 October 2017, the owner-pilot of a Cessna 210B, registered VH-DBU, was operating the aircraft on a private flight without passengers from Albany to Bunbury, within Western Australia. Following take-off, the pilot made a radio broadcast at 1033 Western Standard Time, which was the last recorded transmission from the pilot. The pilot did some local flying before tracking to the north-west of Albany in the general direction of the destination.

At about 1100, people on properties about 30 km to the north-west of Albany heard and in some cases saw the aircraft fly over, and shortly afterwards, witnesses heard a loud cracking sound then one witness saw the aircraft in a steep descent until it disappeared out of sight. Smoke indicated a post-impact fire.

Aircraft wreckage was located in Mount Lindesay National Park and it was established that the pilot was deceased. The wreckage was dispersed over an area of approximately 700 m by 250 m and the fuselage, detached from each wing, was significantly fire affected.

What the ATSB found

The ATSB found that for reasons that were not established, abnormal operation of the aircraft produced high levels of unusual aerodynamic loading on the right wing that exceeded the strength of the wing and initiated an in-flight break-up and impact with terrain.

The aircraft did not have a pre-existing structural deficiency or damage that would have contributed to the in-flight break-up and the local meteorological conditions were not conducive to inadvertent aircraft overstress.

The ATSB found that the presence of methylamphetamine in the pilot’s system increased the risk of operational misjudgements and aircraft mishandling, and pilot incapacitation. This did not necessarily contribute to the accident.

The pilot had worked for a number of organisations which had the required risk controls for problematic alcohol and other drug (AOD) use in place. There was no data that indicated a systemic problem with problematic AOD use in Australian aviation.

What's been done as a result

No safety issues were identified and no proactive safety action was reported to the ATSB. Nonetheless, the ATSB considered that there were opportunities for aviation organisations to collect more data and to enhance the extant risk controls for problematic AOD use.

Safety message

The ATSB acknowledges that self-referral by a pilot with problematic AOD use to a Designated Aviation Medical Examiner, a Drug and Alcohol Management Plan, or the Civil Aviation Safety Authority (CASA), may be perceived as a threat to ongoing employment in aviation. However, the risks to pilots associated with self-referral are less than the health, safety, and legal risks of continuing to operate with problematic substance use.

A defined protocol exists within the CASA aviation medical framework for pilots in stable remission from the problematic use of substances to return to work. Employer and independent peer support organisations are becoming more widely available to assist pilots with the safe return to work.

The ATSB suggests that operators and industry associations consider the availability of information and services to pilots and safety sensitive aviation activities within their area of influence.

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The occurrence

Context

Safety analysis

Findings

General details

Sources and submissions

Preliminary report

Preliminary report

Published: 19 December 2017

On 24 October 2017, the ATSB was advised that wreckage of an aircraft had been located 30 km north-west of Albany Airport, Western Australia. A search had been mounted following a call to emergency services to advise that an aircraft had been seen in a steep descent before it disappeared from sight. Soon afterwards, smoke was observed in the direction of where the aircraft was last seen.

The aircraft was identified as a Cessna 210B, registered VH-DBU, which was being operated by the owner-pilot on a private flight from Albany to Bunbury. The pilot, who was the sole occupant, was fatally injured.

Figure 1: Nominal intended flight path

Figure 1: Nominal intended flight path

Source: Google Earth

The ATSB commenced an investigation and deployed investigators to the accident site. Other than recordings of radio transmissions made in the Albany area, there was no additional recorded data available to provide information about the flight. As a result, the ATSB was reliant on the radio transmissions, witness information and aircraft wreckage to establish the sequence of events.

At Albany Airport, the pilot made routine transmissions to check his radio and on entering the runway to position for take-off. Then, at 1033 (Australian Western Standard Time – AWST), the pilot transmitted that he was airborne from runway 14, maintaining runway heading (to the south-east), intending to make a right turn at 1,500 (ft above mean seal level (AMSL)) to track to Bunbury and climb to 6,500 (AMSL). This was the last recorded radio transmission from the pilot.

People who observed the aircraft start, taxi, and take-off did not notice anything abnormal about the aircraft. From aerial photos of coastal scenery around Albany that the pilot sent to an acquaintance and a report from an Albany resident, it appears that the pilot undertook some local flying before departing the area. There were a few people between Albany and the accident site area that heard an aircraft that could have been VH-DBU, but there was insufficient information to establish the aircraft flight path.

The key witnesses were located between 3 km and 5 km from the accident site in the general direction of Albany. Some witnesses related that prior to any apparent problem with the aircraft, the noise from the aircraft was loud and the aircraft seemed to be lower than was usual (for aircraft operating in that area). For a couple of witnesses, the noise was indicative of an aircraft manoeuvring. In regard to weather, the witnesses reported some cloud but generally clear and calm conditions.

The first sign of a problem was a loud and distinctive noise that witnesses described as a sharp bang, crack of a whip, gunshot, and thunder/lightning. This was an alarming noise that some witnesses associated with the aircraft that had just been heard or seen and prompted them to try and identify it.

Only one of the witnesses, located about 4 km from the accident site, saw the aircraft following the sharp noise. That witness recalled the aircraft was in a nose-down vertical descent rotating to the right and the engine noise was rising and falling. The witness watched the aircraft until it disappeared from sight due terrain and trees. Nothing was seen by the witness to separate from the aircraft and no smoke or vapour was observed coming from the aircraft.

Other witnesses related that, following the initial sharp noise, there were a series of sounds over an extended period (about 10 to 15 seconds according to one witness) that were described as similar to angle grinding or crashing through trees. Other descriptions were chopping, whirring, striking, whining, and high-pitched. One of the witnesses also recalled the engine revving during this time. These irregular noises stopped suddenly, probably upon impact with the terrain.

Figure 2: Accident site location

Figure 2: Accident site location

Source: Google Earth

The aircraft wreckage was located in heavy/dense bushland within the Mount Lindesay National Park. ATSB investigators gained access to the accident site and located wreckage with the assistance of Western Australia Police and the Parks and Wildlife Service.

From the examination of the aircraft wreckage at the accident site, the ATSB makes the following observations:

  • the left wing (Figure 3), right wing, tailplane, and fuselage were not co-located, which is indicative of an in-flight break-up
  • most but not all of the aircraft parts have been identified and these were found within an area of about 700 m long and 250 m wide
  • the items furthest from the fuselage (main wreckage) were pieces of right wing skin and rear fuselage skin
  • the main wreckage, that included the engine and propeller, was severely affected by fire
  • many of the major parts of the aircraft had been damaged in-flight and during the ground impact
  • the right wing outboard of the fuel tank had fragmented in-flight (Figure 4).

Figure 3: Left wing in as found position

Figure 3: Left wing in as found position

Source: ATSB

Figure 4: Right wing inboard section in as found position

Figure 4: Right wing inboard section in as found position

Source: ATSB

The ATSB recovered the wing, tailplane, and selected fuselage pieces to a secure storage location. A subsequent search of the accident site by State Emergency Service personnel located some more pieces of wreckage that were recovered to storage.

The ATSB conducted a further examination of the wreckage pieces and documented the damage for analysis of the break-up sequence and pre-accident airworthiness of the aircraft. No material defects have been identified nor is there direct evidence of an initiating event or action.

The pilot was qualified to conduct the flight and a maintenance release was issued in May 2017 to certify the aircraft as airworthy. At this time, a licenced aircraft maintenance engineer certified for a periodic inspection and compliance with a number of Supplemental Inspection Documents (SIDs). No significant defects were recorded.

The investigation is continuing and will include the following activities:

  • Further analysis of the wreckage characteristics
  • Consultation with the aircraft manufacturer
  • Review of the aircraft maintenance history
  • Review of the pilot records
  • Analysis of meteorological data.

The Civil Aviation Safety Authority (CASA) is participating in the review of the aircraft wreckage and maintenance records to assess the implications (if any) of this occurrence for the continuing airworthiness status of the aircraft type and ageing aircraft in general. If there are any serious implications, the ATSB will communicate these as soon as practicable.

On 7 December 2017, the ATSB released a preliminary investigation report into the in-flight breakup of a Cessna 210 22 km east of Darwin Airport, Northern Territory on 23 October 2017, the day before this accident.

The ATSB acknowledges the support of Western Australia Police in Albany, Parks and Wildlife Service (Department of Biodiversity, Conservation and Attractions) personnel in Albany/Walpole, and State Emergency Service personnel in Albany/Denmark.

________________
The information contained in this preliminary report 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, or change, the ATSB's understanding of the accident as outlined in this preliminary report. As such, no analysis or findings are included in this update.

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General details
Date: 24 October 2017   Investigation status: Completed  
Time: 1100 WST (approximately)   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): 30 km north-west of Albany   Investigation phase: Final report: Dissemination  
State: Western Australia   Occurrence type: In-flight break-up  
Release date: 16 May 2019   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 210B  
Aircraft registration VH-DBU  
Serial number 21057989  
Operator Owner-pilot  
Type of operation General Aviation  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Albany, WA  
Destination Bunbury, WA  
Last update 16 May 2019