Aviation safety investigations & reports

Loss of control and collision with terrain involving BRM Aero Bristell S-LSA aircraft, VH-YVF Moorabbin Airport, Victoria on 12 December 2019

Investigation number:
AO-2019-071
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

Download Final report
[Download  PDF: 1.82MB]
 

Safety summary

What happened

On the morning of 12 December 2019, a student pilot took off for a series of solo circuits in a BRM Aero Bristell, registered VH-YVF, at Moorabbin Airport, Victoria. Just after crossing the runway threshold for the first touch and go landing, witnesses observed the aircraft about 10 ft above the runway, when it suddenly pitched up to about 40 ft. The left wing dropped, with the bank angle increasing to the point where the aircraft became inverted.

The witnesses described what they saw as similar to the aircraft being in the first half rotation of a spin entry. The nose then dropped and the aircraft impacted terrain in a steep inverted attitude. The student pilot was severely injured, and the aircraft was destroyed.

What the ATSB found

The ATSB found that the pilot commenced a go‑around at low level when the aircraft deviated from the runway centreline in crosswind conditions. During the go‑around, the aircraft aerodynamically stalled and commenced a spin.

It was also identified that the student pilot did not have the necessary qualifications and skills to safely operate the Bristell solo.

Finally, the required Soar Aviation solo flight dispatch procedures were not followed. As a result, it was not identified that the student pilot was not authorised for, nor met the required competencies, to conduct the flight.

What has been done as a result

Soar Aviation implemented enhanced measures to ensure student pilots were fully briefed and authorised, before conducting a solo flight. These amended procedures included changes to the aircraft booking procedure and having aircraft keys stored such that they were only accessible by flight instructors.

Soar Aviation ceased flight training on 29 December 2020.

Safety message

Familiarity with an aircraft’s specific systems, controls, handling and limitations is essential for safe flight.

Safety-critical procedures and regulations are in place to ensure that pilots have the required level of skill and experience to safely operate an aircraft. The outcome of this accident, which could just as easily have been fatal, illustrates a consequence of deviating from them.

 

Download Final report
[Download  PDF: 1.82MB]
 
 
 

The investigation

General details
Date: 12 December 2019   Investigation status: Completed  
Time: 9:50 AEDT   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Moorabbin Aerodrome   Investigation phase: Final report: Dissemination  
State: Victoria   Occurrence type: Loss of control  
Release date: 05 May 2021   Occurrence category: Accident  
Report status: Final   Highest injury level: Serious  

Aircraft details

Aircraft details
Aircraft manufacturer BRM Aero S.R.O.  
Aircraft model BRISTELL S-LSA  
Aircraft registration VH-YVF  
Serial number 330  
Operator SOAR AVIATION AIRCRAFT HOLDING PTY LTD  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Substantial  
Departure point Moorabbin, Victoria  
Destination Moorabbin, Victoria  
Last update 05 May 2021