Aviation safety investigations & reports

Engine failure and collision with terrain involving Cessna P210N, N210BA Near Moruya Airport, New South Wales, on 19 December 2019

Investigation number:
AO-2019-075
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

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What happened

At about midday, on 19 December 2019, a turbine‑powered Cessna P210N ‘Silver Eagle’ with United States registration N210BA, departed Bankstown Airport, New South Wales, for a private flight under instrument flight rules to Cambridge Airport, Tasmania. The aircraft was occupied by a pilot and one passenger.

Shortly after reaching the cruise altitude of about 18,000 ft, the aircraft encountered icing conditions. After descending to 16,000 ft, approximately 22 km south‑south‑east of Moruya Airport, the engine experienced a total power loss and could not be restarted. The aircraft subsequently arrived in the vicinity of Moruya Airport at about 8,000 ft above ground level. A glide approach to runway 18 was unsuccessful, and the aircraft impacted terrain about 560 m north of the runway threshold. The aircraft was destroyed, with the pilot seriously injured and the passenger receiving minor injuries.

What the ATSB found

The ATSB found that the accident flight was planned and conducted through forecast icing conditions, for which the aircraft was not certified or equipped.

Continued flight in icing conditions for an extended period resulted in significant accumulation of ice on the airframe. The subsequent descent to avoid further ice build‑up coincided with the pilot deactivating available engine ice-protection systems, which in turn led to an engine flameout from ice ingestion.

Due to the environmental conditions, the engine was unable to be restarted because of a phenomenon known as ‘rotor lock’ however, sufficient height was available to conduct a forced landing at Moruya Airport.

The investigation found that the pilot’s initial manoeuvring during the glide approach resulted in the aircraft being too low to reach the most appropriate runway and subsequent distraction led to a misjudged approach to the remaining runway options.

A number of other factors associated with pre‑flight preparation and the operation of the aircraft and its systems were also identified. The ATSB also found that the seatbelts and shoulder harnesses worn by the pilot and passenger probably reduced the extent of their injuries, and the prompt attendance of nearby paramedics further reduced their risk.

Safety message

Thorough knowledge of an aircraft’s limitations and systems, in combination with an understanding of hazardous weather and aviation meteorological products, is critical to safe and effective flight operations.

Icing conditions can be extremely hazardous to light aircraft and every icing encounter, to some extent, is unique and unpredictable. While inadvertent icing encounters can occur, a cautious approach during planning can reduce the likelihood of encountering these conditions. Pilots should carefully evaluate all available relevant meteorological information when determining whether icing conditions are likely along the planned flight path. Where the aircraft is not certified or equipped to operate in icing conditions, any ice-protection systems on the airframe, propeller, or engine should be regarded as a means to provide time to exit unexpected icing conditions, not to continue to operate in those conditions.

Although forced landings can occur in a variety of circumstances, in general, pilots should focus on remaining visual with the intended landing area in order to accurately assess the aircraft’s performance in glide, and reach key decision points to refine the course of action. Practice and proficiency in simulated forced landings and power-off approaches improves the likelihood of successfully managing these emergencies.

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The occurrence

Context

Safety analysis

Findings

Glossary

Sources and submissions

About the ATSB

Summary

The ATSB is investigating the collision with terrain of a Cessna P210N, registration N210BA, near Moruya Airport, New South Wales, on 19 December 2019.

During cruise, the engine failed and the pilot diverted the aircraft to Moruya. During final approach to land, the aircraft collided with the ground, resulting in substantial damage.

The pilot sustained serious injuries and the passenger sustained minor injuries.

A report will be released at the end of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant stakeholders so appropriate and timely safety action can be taken.

General details
Date: 19 December 2019   Investigation status: Completed  
Time: 1258 ESuT   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Near Moruya Airport   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Engine failure or malfunction  
Release date: 02 November 2021   Occurrence category: Accident  
Report status: Final   Highest injury level: Serious  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model P210N  
Aircraft registration N210BA  
Serial number P21000158  
Type of operation Private  
Sector Turboprop  
Damage to aircraft Substantial  
Departure point Bankstown Airport, New South Wales  
Destination Cambridge Airport, Tasmania  
Last update 02 November 2021