Aviation safety investigations & reports

Severe turbulence and loss of control involving a Cessna 210M, VH-SJW, 30 km south of Darwin Airport, Northern Territory, on 25 November 2019

Investigation number:
AO-2019-069
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 25 November 2019, a Cessna 210M, registered VH-SJW and operated by Mistar Holdings, was conducting a charter flight with four passengers from Darwin to Tindal, Northern Territory. Soon after departure, the pilot diverted 5 NM right of the planned track to avoid a large storm cell that was 5 NM left of track. About 10 minutes after departure, while maintaining 3,500 ft, the aircraft encountered sudden and sustained severe turbulence. Control of the aircraft was lost for over 3 minutes, and three passengers sustained minor injuries.

After landing at Tindal and inspecting the aircraft for potential damage, the pilot ferried the aircraft to Millingimbi. At Millingimbi, the pilot picked up four more passengers for a charter to Galiwin’ku (Elcho Island). The pilot reported the incident to the operator that evening. Upon receiving notification of the turbulence encounter, the operator grounded VH-SJW at Galiwin’ku, pending an engineering inspection.

What the ATSB found

At 10 NM from the thunderstorm, the pilot did not have sufficient separation to ensure safe passage.

Following the incident, the inspection carried out by the pilot was not sufficient to ensure the airworthiness of the aircraft beyond doubt. Flying another charter flight without an aircraft inspection by a qualified person exposed the operator, the pilot, and the passengers to elevated risk. In addition, the operator did not have guidance to direct pilots to seek advice or peer support following abnormal events.

What has been done as a result

The operator has developed case studies for pilots, emphasising weather avoidance and management of abnormal events. These have been integrated into proficiency checks to ensure solid understanding of theory, and practical application of weather avoidance, escape and post encounter management.

Safety message

The primary protection against thunderstorm related turbulence is avoidance. In this case, 10 NM was not far enough. Operators, pilots and passengers can work together to avoid flying in adverse weather. For instance, by starting a day’s flying early it can be completed before weather becomes a problem in the afternoon.

A pilot with the best intentions may make a suboptimal decision after experiencing an abnormal event. Operators can provide guidance to assist pilots to make good decisions in these situations, by providing peer support and emphasising the importance of reporting abnormal events in a timely manner. Early reporting reduces pressure in operations, allowing ample time to make alternative arrangements.

To support continuous improvement in performance, pilots should regularly review operational documents and industry advice, to build on experience, and develop a comprehensive knowledge of issues and strategies available.

Download final report
[Download  PDF: 633KB]
 
 
 

The investigation

General details
Date: 25 November 2019   Investigation status: Completed  
Time: 1345 CST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): 30 km south of Darwin Airport   Investigation phase: Final report: Dissemination  
State: Northern Territory   Occurrence type: Turbulence/windshear/microburst  
Release date: 15 September 2020   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: Minor  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 210M  
Aircraft registration VH-SJW  
Serial number 21062219  
Operator Mistar Holdings  
Type of operation Charter  
Sector Piston  
Damage to aircraft Nil  
Departure point Darwin, Northern Territory  
Destination Tindal, Northern Territory  
Last update 15 September 2020