Aviation safety investigations & reports

Collision with terrain involving Cessna 210, VH-SUX, 25 km NE Mount Isa Airport, Queensland on 26 May 2019

Investigation number:
AO-2019-026
Status: Active
Investigation in progress

Update

Updated: 20 March 2020

The information contained in this investigation update is derived from the initial investigation of the occurrence. Readers are cautioned that there is the possibility that new evidence may become available that alters the circumstances as depicted in the report.

The ATSB’s investigation into the in-flight break-up involving a Cessna 210M (C210), 25 km north east of Mount Isa Airport, Queensland is continuing. The information published in this update supplements the details provided in the ATSB preliminary report published on 7 June 2019.

On 26 May 2019, a C210 registered VH-SUX and operated by Thomson Aviation, departed Mount Isa Airport for a geological survey flight. During the flight, the aircraft’s right wing separated, resulting in a rapid loss of control and collision with terrain. The pilot and observer were fatally injured and the aircraft was destroyed.

Subsequent technical examination of the wing spar carry-through structure found that fatigue cracking had reduced the structural integrity of the carry‑through. This cracking progressed to the extent that in-flight operational loads produced an overstress fracture of the remaining material during the accident flight.

The investigation is currently continuing to collect further evidence, with the examination and analysis phase well progressed.

In addition to the initial activities outlined in the preliminary report, the ATSB’s investigation has included the following activities to date:

  • detailed examination of the aircraft wreckage
  • examination of the maintenance procedures associated with the wing spar carry-through structure
  • review of the maintenance and operational history of the aircraft
  • analysis of the effects of modifications to the airframe and systems of VH-SUX (preliminary report also refers)
  • review of the manufacturer’s service letter (detailed below), inspection findings, and communications with Australian C210 and Cessna 177 (C177) operators and maintenance providers on the findings of these inspections
  • analysis of data recorded by the aircraft’s survey equipment including the accident flight and break-up sequence
  • review of the fatigue loading spectrum of similar operation types.

As a result of the accident, the following safety action has been taken:

  • On 31 May 2019, the ATSB notified the Civil Aviation Safety Authority (CASA), the United States National Transportation Safety Board, the aircraft manufacturer, and the operator of the initial finding of fatigue cracking within the wing spar carry-through structure.
  • On 7 June 2019, the ATSB published a preliminary report containing the initial findings of the investigation.
  • On 24 June 2019, the manufacturer released Service Letters SEL-57-06 for the C210 and SEL-57-07 for the C177. These Service Letters instructed a one-off inspection of the structure and communication of inspection findings to the manufacturer.
  • On 25 June 2019, the United States Federal Aviation Administration (FAA) released an Airworthiness Concern sheet supporting the manufacturer’s Service Letters and requesting further information from aircraft operators.
  • On 12 July 2019, CASA released an Airworthiness Bulletin providing additional information to assist in managing the airworthiness of C210 and C177 wing carry-though spar structures.
  • On 4 November 2019, following the receipt and analysis of results from the previously released Service Letters, the manufacturer released updated Service Letters SEL-57-08 for the C210 and SEL-57-09 for the C177. On 19 November 2019, the manufacturer released further revisions to these updated Service Letters.
  • On 21 February 2020, the FAA adopted airworthiness directive (AD) AD 2020-03-16 for all Cessna model 210G, T210G, 210H, T210H, 210J, T210J, 210K, T210K, 210L, T210L, 210M, and T210M aircraft. This AD requires:
    • visual and eddy current inspections of the carry through spar lower cap
    • corrective action if necessary
    • application of a protective coating and corrosion inhibiting compound
    • reporting the inspection results to the FAA.

This AD was prompted by both the in-flight break-up of VH-SUX and subsequent reports of other C210 aircraft with widespread and severe corrosion.

Once the examination and analysis phase is complete, a final report will be drafted and undergo a rigorous internal review to ensure the report findings adequately and accurately reflect the analysis of available evidence. Following the completion of the internal review, a draft of the final report will be sent to all directly involved parties for their comment before the report is finalised and published.

The ATSB final report is anticipated to be published in the third quarter of 2020.

Preliminary

Preliminary: 7 June 2019

The information contained in this update is derived from the initial investigation of the occurrence. Readers are cautioned that there is the possibility that new evidence may become available that alters the circumstances as depicted in the report.

What happened

At 1407 Eastern Standard Time[1] on 26 May 2019, a Cessna Aircraft Company 210M, registered VH-SUX and operated by Thomson Aviation, departed Mount Isa Airport for an aerial geological survey flight. There were two pilots on board, one operating the aircraft and the other observing the flight to familiarise himself with the survey area. The survey was to be conducted at a target height of about 200 ft above ground level along parallel east and west lines, spaced about 90 m apart.

The evidence indicated that about 1 hour and 40 minutes into the flight, as the aircraft tracked west along the sixth survey line, the right wing separated, resulting in a rapid loss of control and subsequent collision with terrain. The pilots were fatally injured and the aircraft was destroyed.

Wreckage and site information

The accident site was located about 25 km north-east of Mount Isa Airport in flat, arid scrub land (Figure 1). The wreckage trail was on an approximate east to west heading, in line with the expected survey flight path. The right wing was the first major component in the wreckage trail and was located about 130 m from the main wreckage. The aircraft impacted terrain about 90 m from the right wing, coming to rest a further 40 m away. All major aircraft components were accounted for at the site.

Figure 1: Accident site overview looking east

Figure 1: Accident site overview looking east. Source: ATSB

Source: ATSB

On-site examination of the wreckage indicated the right wing and part of the carry-through spar[2] had separated from the aircraft (Figure 2). Preliminary examination of the spar identified that it had fractured through an area of pre-existing fatigue cracking. The fracture was located inboard of the wing attachment lugs.

The carry-through structure was removed for detailed examination.

Figure 2: Right wing viewed from inboard end showing section of carry-through structure

Figure 2: Right wing viewed from inboard end showing section of carry-through structure. Source: ATSB

Source: ATSB

Initial findings

Technical examination of the carry-through structure was conducted at the ATSB’s Canberra facilities. This examination confirmed that the fatigue cracking reduced the structural integrity of the carry‑through to the point where operational loads produced an overstress fracture of the remaining material. The fracture location was approximately 290 mm inboard of the right wing fuselage attachment lugs and coincident with a change in section thickness of the lower flange (Figures 3, 4 and 5). Characteristic features identified across the fracture surfaces confirmed that the fatigue cracking had initiated from the underside surface, growing across the lower flange and penetrating vertically into the structure.

Figure 3: The approximate location of fracture

Figure 3: The approximate location of fracture. Source: Cessna, modified by the ATSB

Source: Cessna, modified by the ATSB

Figure 4: Carry-through structure, as received at the ATSB’s facilities

Figure 4: Carry-through structure, as received at the ATSB’s facilities. Source: ATSB

Source: ATSB

Figure 5: Close view of the outboard portion of the fracture surface (fatigue cracking has initiated on the underside surface)

Figure 5: Close view of the outboard portion of the fracture surface (fatigue cracking has initiated on the underside surface). Source: ATSB

Source: ATSB

Aircraft details

The Cessna Aircraft Company (Cessna) 210M is a high cantilever wing, piston-engine aircraft with a three-blade variable-pitch propeller and retractable tricycle landing gear (Figure 6). The aircraft is normally fitted with six seats. The accident aircraft (serial number 21061042) was manufactured in the United States in 1976 where it operated until 2013. It was imported to Australia and registered as VH-SUX in June 2013. At that time, the aircraft was modified for geological survey work, which included the removal of the passenger seats and the installation of specialised equipment.

Figure 6: VH-SUX

Figure 6: Cessna 210M, registered VH-SUX. Source: Operator

Source: Operator

The aircraft also had Supplemental Type Certificates for the installation of integral wing tip fuel tanks and a non-standard engine and propeller installation.

VH-SUX accumulated about 6,000 flight hours in the 6 years it was on the Australian register. It was operated exclusively as a geological survey aircraft during that time. The aircraft had 12,174 flight hours total time in service at the time of the accident.

Operation

The flight was one of a number of flights undertaken for the purpose of a geological survey to the north and north-east of Mount Isa.

The survey was conducted in a grid pattern, with closely spaced east and west lines along with more widely spaced north and south lines flown for data verification purposes. The flight profile closely followed the topography of the survey area at a speed of about 140-150 kt with procedure turns flown at each end of a survey line.

Each flight typically lasted for about 5 hours with multiple flights required to complete each survey. Two flights were normally flown each day in accordance with allowable environmental and daylight conditions, each flight on a given day being operated by a different pilot.

The aircraft typically departed with full fuel, resulting in it operating at close to the maximum allowable take-off weight.

Safety action

On 31 May 2019, the ATSB notified the Civil Aviation Safety Authority, the US National Transportation Safety Board, the aircraft manufacturer and operator of the initial finding of fatigue cracking within the wing spar carry-through structure.

The ATSB is working closely with those organisations to ensure the continued safe operation of the aircraft type.

Further investigation

The investigation is continuing and will include:

  • a metallurgical examination of the wing carry-through structure and associated parts
  • further examination and assessment of the aircraft wreckage
  • examination of the maintenance procedures and inspections associated with the wing spar carry-through structure
  • factors that may have contributed to the development of fatigue cracking
  • the operational history of the aircraft from 1976 until 2013.

_____________

The information contained in this 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 update. As such, no analysis or findings are included.

 

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  1. Eastern Standard Time (EST): Universal Coordinated Time (UTC) + 10 hours.
  2. A major span-wise structural member to which the wings are attached.
General details
Date: 26 May 2019   Investigation status: Active  
Time: 1547 AEST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): 25 km NE of Mount Isa Airport   Investigation phase: Examination and analysis  
State: Queensland   Occurrence type: Collision with terrain  
Release date: 07 June 2019   Occurrence category: Accident  
Report status: Pending   Highest injury level: Fatal  
Anticipated completion: 3rd Quarter 2020    

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model T210M  
Aircraft registration VH-SUX  
Serial number 21061042  
Operator Thomson Aviation  
Type of operation Aerial Work  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Mount Isa, Queensland  
Destination Mount Isa, Queensland  
Last update 28 April 2020