Aviation safety investigations & reports

Wheels-up landing involving Beech Aircraft Corporation B200, VH-ODI, Mount Gambier Airport, South Australia, on 8 December 2018

Investigation number:
AO-2018-080
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 8 December 2018, a Desert-Air Safaris Beech Aircraft Corporation B200, registered VH-ODI operated a charter flight from Adelaide Airport to Mount Gambier Airport, South Australia with a pilot and seven passengers on board. One of the passengers held a commercial pilot licence and acted in an observer role from the right flight deck seat, but was not a member of the flight crew.

During the landing at Mount Gambier, the aircraft touched down with the landing gear retracted, with the propellers contacting the runway twice before the pilot initiated a go‑around. During the go-around, the left engine failed. The aircraft then landed without further incident.

What the ATSB found

The ATSB found that upon reaching the minimum descent altitude for an approach to Runway 18 at Mount Gambier, the pilot had not yet obtained visual reference with the runway. He therefore commenced a go-around and retracted the landing gear. After retracting the landing gear, the pilot sighted the runway and decided to continue the approach, but inadvertently did not re-extend the landing gear.

During the continued approach, the pilot likely did not detect the retracted landing gear due to an expectation that it was already extended. This was possibly also compounded by the now‑increased workload.

Further, the ATSB found that the pilot’s decision to conduct a go-around after the wheels-up landing stemmed from his misunderstanding of the situation, and an assessment that a runway overrun was imminent.

Safety message

This accident highlights the hazards of spontaneous decision-making, particularly during a high‑workload phase of flight in a complex aircraft. The Civil Aviation Safety Authority Resource booklet and video Decision Making provides the following tips to improve the quality of decision making, mitigate the possibility of errors and ensure a considered approach in resolving issues or problems:

  • You cannot improvise a good decision, you must prepare for it. You will make a better and timelier final decision if you have considered all options in advance. This is why good briefings are important.
  • Use decision-making aids—operational checklists—to ensure you have not forgotten anything important.
  • Always have reserve capacity for reacting to unexpected events.
  • Delegate your load to other team members (if multi-crew) when time is critical.
  • Keep the big picture in mind rather than focusing on one aspect of a problem.
Download final report
[Download  PDF: 823KB]
 
 
 

The occurrence

Context

Safety analysis

Findings

General details

Sources and submissions

General details
Date: 08 December 2018   Investigation status: Completed  
Time: 1222 ACDT   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Mount Gambier Airport   Investigation phase: Final report: Dissemination  
State: South Australia   Occurrence type: Wheels up landing  
Release date: 20 May 2020   Occurrence category: Accident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Beech Aircraft Corp  
Aircraft model 200  
Aircraft registration VH-ODI  
Serial number BB-634  
Operator Desert-Air Safaris  
Type of operation Charter  
Sector Turboprop  
Damage to aircraft Substantial  
Departure point Adelaide, South Australia  
Destination Mount Gambier, South Australia  
Last update 20 May 2020