Aviation safety investigations & reports

Runway overrun involving Gippsland Aeronautics GA-8, VH-WSB East Wallabi Island, Western Australia on 26 December 2021

Investigation number:
AO-2022-001
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

Download Final report
[Download  PDF: 657KB]
 

What happened

On the morning of 26 December 2021, the pilot of a Geraldton Air Charter, Gippsland Aeronautics GA-8 Airvan prepared for an air-transport flight from Geraldton, Western Australia to East Wallabi Island. During the preparations, the pilot decided to carry an additional passenger from another flight, which was also scheduled to depart for East Wallabi Island. The pilot later reported that the rearrangement of the passengers resulted in the preparations for the flight being rushed.

Earlier in the day, the pilot had operated a flight in a Cessna 172 with an emergency position indicating radio beacon (EPIRB) positioned on their right hip. The pilot was aware that this would obstruct the flap lever in the Airvan and intended to move the EPIRB to their left hip prior to the East Wallabi flight, but during the rushed preparations, forgot to move it.

As the aircraft approached East Wallabi Island, the pilot attempted to select full flap for the landing, but the EPIRB obstructed the flap lever movement and prevented it from locking into the full flap position. Multiple further attempts to select full flap were unsuccessful, and the approach was continued with only the first stage of flap extended.

During the landing flare, the aircraft floated more than the pilot expected and touched down about midway along the runway (about 350 m from the end of the runway). After touch down the pilot applied normal braking but, as the aircraft approached the end of the runway, they realised an overrun was imminent and applied maximum braking. Despite that, the aircraft did not stop on the runway and overran it by about 15 m. The pilot and passengers were not injured, and the aircraft was substantially damaged in the accident.

What the ATSB found

The ATSB found that an emergency position indicating radio beacon worn by the pilot prevented the selection of full flap. The pilot possibly did not comprehend the effect of the reduced flap setting and continued the approach with the inappropriate flap setting.

During the subsequent landing, the aircraft floated significantly beyond the intended landing point. The pilot did not recognise the risk of a runway overrun and did not conduct a go around or apply sufficient braking to stop the aircraft on the remaining runway.

What has been done as a result

Following the accident, the operator modified their operating procedures to recommend that a process of threat and error management be conducted before all flights.

Safety message

This accident emphasises the need for careful flight preparation. Taking time to confirm that all required actions have been completed prior to departure minimises the chance of in-flight complications. To ensure effective flight preparation, the Civil Aviation Safety Authority publication: Visual Flight Rules Guide advises pilots to ‘give yourself time to review information free from distractions when making pre-flight decisions…avoid flying under time pressure’.

It also underlines the importance of commencing a missed approach early when the approach and landing deviate from the plan and a safe landing cannot be assured.

The Civil Aviation Authority of New Zealand publication: Good Aviation Practice, Mountain Flying recommends that pilots ‘always have a clearly defined decision point where you can go-around if you are not happy that a safe landing is achievable.’ This is especially relevant for operations involving short runways.

Download Final report
[Download  PDF: 657KB]
 
 
 

The investigation

Summary

The ATSB has commenced a transport safety investigation into a runway excursion involving a Gippsland Aeronautics GA-8, registered VH-WSB, at East Wallabi Island, Western Australia on 26 December 2021.

After landing, the aircraft overran the runway by about 20 metres, which resulted in its right main landing gear collapsing. The pilot and 5 passengers on board were not injured.

The ongoing investigation will collect and examine relevant evidence, including interviewing the pilot, analysing relevant weather data, photographs, aircraft operator procedures and records.

A final report will be published at the conclusion of the investigation, however, should any critical safety issues be identified at any stage during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate safety action can be taken.

General details
Date: 26 December 2021   Investigation status: Completed  
Time: 1100 WST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): East Wallabi Island   Investigation phase: Final report: Dissemination  
State: Western Australia   Occurrence type: Runway excursion  
Release date: 06 May 2022   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Gippsland Aeronautics Pty Ltd  
Aircraft model GA-8  
Aircraft registration VH-WSB  
Serial number GA8-07-125  
Operator GERALDTON AIR CHARTER PTY LTD  
Type of operation Air Transport Low Capacity  
Sector Piston  
Damage to aircraft Substantial  
Departure point Geraldton Aerodrome, Western Australia  
Destination East Wallabi Island, Western Australia  
Last update 06 May 2022