Aviation safety investigations & reports

Loss of control and collision with terrain involving BRM Aero S.R.O Bristell LSA aircraft, VH-YVX, at Stawell, Victoria, on 5 October 2018

Investigation number:
AO-2018-066
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
[Download  PDF: 930KB]
 

What happened

On 5 October 2018, a BRM Aero Bristell light sport aircraft (LSA), registered VH-YVX, departed Moorabbin Airport, Victoria, with a pilot and passenger on board. The purpose of the flight was a navigation exercise in support of the pilot’s commercial pilot training requirements. Following an overfly of the intended waypoint at Stawell Airport, the aircraft was observed by witnesses to conduct a number of aerobatic‑type manoeuvres before control was lost. The pilot was unable to recover control of the aircraft before it impacted terrain. The occupants sustained significant injuries and the aircraft was destroyed.

What the ATSB found

The ATSB determined that, contrary to the aircraft’s limitations and the pilot’s qualifications, aerobatic manoeuvres were conducted during the flight, and immediately prior to the loss of control. The aircraft experienced an accelerated aerodynamic stall and entered into an upright, fully‑developed spin. Although the pilot did not consistently apply the manufacturer’s recommended spin recovery technique, recovery from a fully‑developed spin may not have been possible in the aircraft type.

The avionics system fitted to the accident aircraft had data storage capability and also backup storage capability by way of a secure digital (SD) card which could be fitted to the avionics system. An SD card was not fitted as standard equipment when Bristell aircraft were delivered to operators from new. Further, the operator was not aware of the additional memory card storage capability and had not installed SD cards in any of their Bristell fleet.

What's been done as a result

Following a number of fatal spin‑related accidents involving BRM Aero Bristell aircraft in Australia and overseas, the Civil Aviation Safety Authority (CASA) reviewed the flight test data supplied by the aircraft manufacturer against the ASTM standard for which the manufacturer self‑certifies compliance. CASA found that there was not enough information in the initial and follow-up test data to provide them with assurance that the aircraft type meets the required standards for spin recovery. At the time of writing the final investigation report, the manufacturer and CASA were still in discussion.

The operator conducted a fleet-wide installation of SD cards to all aircraft capable of storing data.

Safety message

Aerobatic flight should not be undertaken by pilots who have not been adequately trained, as it requires specialist techniques and methods to maintain control of the aircraft during significant manoeuvring. Further, aircraft manufacturers that prohibit aerobatics in certain aircraft types do so because the aircraft has not been designed and/or tested to ensure these manoeuvres can be conducted safely. This accident clearly demonstrates the catastrophic consequences when the hazards of aerobatic flight are not managed.

Aircraft data recording systems can be a readily accessible tool for both flying training, maintenance and safety investigation. Aircraft owners should make themselves aware of the data recording capability of their aircraft and ensure that the systems are fully functioning and backing up information.

Download final report
[Download  PDF: 930KB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Pilot details

Sources and submissions

Preliminary report

Preliminary report published: 21 November 2018

What happened

On 5 October 2018, at about 1120 Eastern Daylight‑saving Time,[1] a Bristell Light Sport Aircraft, registered VH-YVX, departed Moorabbin Airport, Victoria, with a pilot and passenger onboard. The purpose of the flight was a navigation exercise in support of the pilot’s commercial pilot training requirements. The passenger held a student pilot licence but his aviation medical certificate was not current.

At about 1240, following an overfly of the intended waypoint at Stawell Airport, the aircraft was observed by witnesses to conduct a 180° turn towards the east at about 1,500 ft above ground level (Figure 1). Following the turn the aircraft was observed to commence a number of manoeuvres before entering a spin. The pilot was unable to recover control of the aircraft before it impacted terrain.

Figure 1: Aircraft’s flight path and accident site location

Figure 1: Aircraft’s flight path and accident site location. Source: Google earth, with Airservices surveillance radar data. Annotated by the ATSB

Source: Google earth, with Airservices surveillance radar data. Modified by the ATSB

A witness at the aerodrome notified emergency services about the accident. Two other witnesses at the aerodrome utilised an aircraft to locate the accident site, and guided the emergency services to its location. The pilot and passenger sustained significant injuries and were airlifted to hospital. The aircraft was destroyed.

Site and wreckage examination

The ATSB conducted an examination of the accident site and wreckage (Figure 2). This examination identified that the:

  • aircraft was located in relatively flat and open farmland, which was about 1.7 km south‑east of Stawell Airport
  • ground impact marks indicated that the aircraft had impacted terrain in a relatively flat, upright, counter clock-wise spin
  • flaps were in the retracted position
  • elevator trim was in a neutral position.

No pre-impact defects were identified with the flight controls or aircraft structure.

A panel‑mounted avionics unit was removed from the aircraft and taken to the ATSB’s technical facility in Canberra for examination. The stored information was successfully downloaded and included numerous flight and engine parameters recorded during the accident flight.

Figure 2: Accident site of Bristell Light Sport Aircraft, registered VH-YVX

Figure 2: Accident site Bristell Light Sport Aircraft, registered VH-YVX. Source: ATSB

Source: ATSB

Ongoing investigation

The investigation is continuing and will include:

  • interviews with parties involved in the accident
  • analysis of the downloaded data from the avionics unit and other electronic devices
  • examination of the pilot’s qualifications, experience and medical history
  • assessment of the aircraft’s flight performance characteristics
  • examination of aircraft maintenance and operational records
  • examination of the training organisation records and procedures.

 

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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 the ATSB's understanding of the accident as outlined in this update. As such, no analysis or findings are included in this update.

 

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  1. Eastern Daylightsaving Time (AEDT): Coordinated Universal Time (UTC) + 11 hours.
General details
Date: 05 October 2018   Investigation status: Completed  
Time: 1240 EDT   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): 1.7 km SE Stawell Airport   Investigation phase: Final report: Dissemination  
State: Victoria   Occurrence type: Collision with terrain  
Release date: 29 June 2020   Occurrence category: Accident  
Report status: Final   Highest injury level: Serious  

Aircraft details

Aircraft details
Aircraft manufacturer BRM Aero S.R.O.  
Aircraft model BRM Aero Bristell LSA  
Aircraft registration VH-YVX  
Serial number 284  
Operator Soar Aviation  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Moorabbin, Victoria  
Destination Moorabbin, Victoria  
Last update 29 June 2020