Aviation safety investigations & reports

Collision with water involving Cessna 208B, VH-FAY, 185 km NE of Tokyo, Japan, on 27 September 2018

Investigation number:
AO-2018-065
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

The pilot of a Cessna 208B aircraft, registered VH-FAY (FAY), was contracted by the aircraft operator to ferry FAY from Jandakot Airport, Western Australia to Mississippi, United States. On the morning of 27 September 2018 local time, the aircraft departed Saipan International Airport, Northern Mariana Islands, for a planned flight to New Chitose Airport, Hokkaido, Japan. After climbing for about an hour, the aircraft levelled off at flight level (FL) 220.

After 2 hours 20 minutes flight time, the pilot contacted Tokyo Radio flight information service at the first mandatory reporting position. The aircraft passed the next reporting point at the same altitude, 1 hour 20 minutes later, but the pilot did not contact Tokyo Radio as expected. Tokyo Radio made repeated attempts to communicate with the pilot, without success. Having received no communications from the pilot for 4.5 hours, two Japan Air Self‑Defense Force (JASDF) aircraft intercepted FAY. The pilot did not manoeuvre the aircraft in response, in accordance with international intercept protocols.

After about 30 minutes, the JASDF pilots observed FAY descend into cloud. The aircraft descended rapidly and disappeared from radar less than 2 minutes later. Within 2 hours, search and rescue personnel located the aircraft’s rear passenger door. No other aircraft parts were located and the pilot was not found.

What the ATSB found

While the aircraft was in the cruise on autopilot, the pilot almost certainly became incapacitated and did not recover. About 5 hours after the last position report, without pilot intervention to select fuel tanks, the aircraft’s engine stopped, likely due to fuel starvation. This resulted in the aircraft entering an uncontrolled descent into the ocean.

The cause of incapacitation could not be determined. While a medical event could not be ruled out, the pilot was operating alone in an unpressurised aircraft at 22,000 ft and probably using an unsuitable oxygen system, which increased the risk of experiencing hypoxia and being unable to recover.

What's been done as a result

The aircraft operator amended their operations manual to include additional guidance for international ferry flights. They also created an oxygen use guide and a specific risk assessment for positioning (ferry) flights.

Safety message

Operating unpressurised aircraft above 10,000 ft requires careful oxygen management and planning. Where an increased risk of hypoxia exists, good risk management practices should be used for flight planning. Because the effects of hypoxia can be insidious, training in recognition of early symptoms of hypoxia can increase the time available to react, descend and resolve any issues. The Flight Safety Australia (2014) article Do not go gentle: the harsh facts of hypoxia provides further information, including anecdotal experiences of hypoxia.

VH-FAY with full survey equipment installed

Cessna 208B aircraft, registered VH-FAY with full survey equipment installed.
Source: Sid Mitchell, Aviation Spotters Online

Source: Sid Mitchell, Aviation Spotters Online

Download final report
[Download  PDF: 1.39MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety actions

Sources and submissions

General details
Date: 27 September 2018   Investigation status: Completed  
Time: 0626 UTC   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): 185 km north-east of Narita International, Japan   Investigation phase: Final report: Dissemination  
State: International   Occurrence type: Collision with terrain  
Release date: 18 March 2020   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 208B  
Aircraft registration VH-FAY  
Serial number 208B0884  
Operator CGG Aviation (Australia)  
Type of operation Private  
Sector Turboprop  
Damage to aircraft Destroyed  
Departure point Saipan, Federated States of Micronesia  
Destination New Chitose Airport, Hokkaido, Japan  
Last update 18 March 2020