Aviation safety investigations & reports

Collision with terrain involving amateur-built Osprey 2 amphibian aircraft, registered VH-WID near Maitland Airport, New South Wales on 17 May 2020

Investigation number:
AO-2020-028
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

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What happened

Mid-morning on 17 May 2020 an experimental amateur-built Osprey 2 amphibious aircraft, registered VH-WID (WID), took off from Maitland Airport, New South Wales, for a local private flight. The pilot was the sole occupant and was conducting the aircraft’s second test flight.

During the climb, passing 2,400 ft, the pilot was advised, via radio, of white smoke coming from the aircraft and noted that the engine was not running smoothly. In response, the pilot broadcast that they were returning to land on runway 23. However, during the descent they turned to join the reciprocal runway 05. As the aircraft was turned on to the base leg of the circuit the engine failed, and the pilot attempted to conduct a forced landing on to the closer runway 08. During the final stage of the glide approach, the aircraft was observed to abruptly roll, pitch down and collide with terrain.

What the ATSB found

The ATSB found that the use of a damaged engine oil cooler fitting, which was not compatible with the fitted oil hose, most likely resulted in the hose disconnecting from the oil cooler during the climb, and the loss of oil from the engine.

During the return to the airport, the airborne duration and engine power required to maintain height were both increased when the pilot decided to change runways. This resulted in the engine failing due to oil starvation as the aircraft was turning on to the base leg of the circuit. During the subsequent forced landing, control of the aircraft was lost due to an aerodynamic stall at a height too low for recovery.

It was also identified that neither the required, nor the majority of the recommended stage build inspections of the aircraft were conducted. This was not detected prior to the issuance of a certificate of airworthiness that permitted the aircraft to be flown. While these inspections would probably not have detected the damaged fitting, they may have identified that the oil supply hose was in poor condition. They would also have been an opportunity to identify and improve the overall build quality of the aircraft.

The ATSB also identified a number of other deficiencies relating to the inspection and flight testing of amateur‑built aircraft, including the risk assessment of the proposed test pilot.

What has been done as a result

As a result of this investigation, the Sport Aircraft Association of Australia (SAAA) amended the Authorised Person’s Manual of Procedures and submitted it to the Civil Aviation Safety Authority (CASA) for approval. The revisions to the manual:

  • stated that if the authorised person considered that an aircraft was unsafe, they were not required to issue a certificate of airworthiness and could refer the matter to CASA
  • clarified that the Risk Radar Aviation report must be endorsed in writing by both the technical counsellor (TC) and the builder
  • required that the authorised person (AP) receive 3 technical counsellor reports
  • required the AP to name the pilot who would be conducting the initial test flying of the aircraft in the limitations
  • required that any changes made to the aircraft after the certificate of airworthiness was issued be notified to the AP
  • clarified that a TC or AP cannot inspect their own aircraft.

The SAAA also updated their other manuals to reflect these changes.

In addition, the SAAA have written to CASA to request an urgent 1-day refresher training course for all authorised persons and annual refresher training courses be made available. They have also amended their procedures to mandate that 3 stage inspections, inclusive of the final inspection, are conducted by a technical advisor (or equivalent) on the aircraft during the build. The SAAA have also requested that CASA provide them with a summary of the audits conducted on authorised persons to ensure they are aware of issues which may arise.

Safety message

As stated in the ATSB publication, Avoidable Accidents No. 3 - Managing partial power loss after take-off in single-engine aircraft, managing a partial engine failure is often a more complex scenario than a complete engine failure. The course of action chosen can be strongly influenced by the engine producing some power. Pilots are advised that as the engine could stop at any stage, the aircraft should be landed at the earliest opportunity and consideration should be given to forced landing options along the flight path.

This accident also highlights the importance of adhering to the design specifications and good engineering practices when building an amateur-built experimental aircraft. Attention should be given to the component manufacturer’s specifications, installation instructions and limitations to ensure the component, and consequently the aircraft, will perform as intended.

Consideration should also be given to having independent inspections during the build process. Independent inspections conducted during the early stages of the build, and prior to closing components such as the wings and fuselage, will assist in ensuring the builder has used accepted practices and reduce the likelihood of inadvertent construction errors.

Finally, while most amateur-built aircraft are built to a high standard consideration should be given to the use of a professionally‑trained test pilot for the initial test flying. Use of the Sport Aircraft Association of Australia’s risk assessment tool, and consultation with their Flight Safety Advisors, can significantly assist the test flying stage.

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The occurrence

Context

Safety analysis

Findings

Safety action

Glossary

Sources and submissions

Appendices

About the ATSB

Preliminary report

Preliminary report published 26 June 2020

The information contained in this preliminary report 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 in this report.

The occurrence

On 17 May 2020, at 1002 Eastern Standard Time,[1] an amateur-built Osprey 2 amphibian aircraft, registered VH-WID, departed Maitland Airport, New South Wales on a private flight (Figure 1). The flight was intended as a test flight and the pilot was the sole occupant. This was the third flight for the aircraft, which was operating under a special certificate of airworthiness – experimental. This certificate required that 25 hours of flight-testing be conducted.

The aircraft took off to the south-west from runway 23[2] before turning left, with the intention to climb to 3,000 ft and conduct the flight-testing over the airfield.

Figure 1: VH-WID

Figure 1: VH-WID
Source: Aircraft owner

Source: Aircraft owner

About 3 minutes after the take-off, a number of people observed white smoke coming from the aircraft and a person on the ground informed the pilot over the radio about the smoke. The pilot replied that the engine was running rough and that the intent would be to return to the airport for a landing on runway 23. Witnesses then observed the aircraft circling while descending over the north of the airport.

Figure 2: Maitland Airport

Figure 2: Maitland Airpor .
Source: Google Earth, annotated by ATSB

Source: Google Earth, annotated by ATSB

At 1010, the pilot reported on the downwind leg of the circuit for runway 05 (the opposite direction to which the aircraft took off). This circuit took the aircraft to the north and west of the airport. The engine subsequently failed completely and the pilot reported changing to runway 08.

A number of witnesses observed the aircraft on approach to runway 08 and reported that the aircraft appeared to be low and slow. The witnesses reported that there was no engine sound, and several reported that they observed the propeller to be stationary. The aircraft was observed to roll to the left, descend and impact terrain (Figure 3). Residents of the adjoining properties attempted to rescue the pilot and provide first aid; however, the pilot sustained fatal injuries. The aircraft was destroyed.

Figure 3: VH-WID at accident site

Figure 3: VH-WID at accident site.
Source: ATSB

Source: ATSB

Ongoing investigation

The investigation is continuing and will include examination of:

  • the aircraft’s engine
  • aircraft maintenance documentation and operational records
  • aircraft build documentation
  • recovered instruments and electronic devices
  • aircraft performance characteristics and recorded flight data
  • pilot qualifications and experience.

Should any safety critical information be discovered at any time during the investigation, the ATSB will immediately notify operators and regulators so appropriate and timely safety action can be taken.

A final report will be published at the conclusion of the investigation.

__________

  1. Eastern Standard Time (EST): Coordinated Universal Time (UTC) + 10 hours.
  2. Runways are described by their magnetic heading, rounded to the nearest 10 degrees and expressed in 2 digits representing the 100’s and 10’s of degrees. Runway 23 at Maitland Airport is aligned with a magnetic heading of 225°.
General details
Date: 17 May 2020   Investigation status: Completed  
Time: 1000 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): near Maitland Airport   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Collision with terrain  
Release date: 04 April 2022   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Amateur Built Aircraft  
Aircraft model Osprey 2 Amphibian  
Aircraft registration VH-WID  
Serial number WJC 003  
Type of operation Private  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Maitland Airport, New South Wales  
Destination Maitland Airport, New South Wales  
Last update 04 April 2022