Collision with terrain

The pilot and passenger were conducting inspections at various company facilities in the area. They had landed at a drilling site for an inspection which lasted over one hour. After a routine start-up and lift-off to a low hover, the helicopter commenced to move forward but the main rotor blades struck the ground.

The pilot considered that he had been unable to obtain correct cyclic control response during the take-off. No faults were found to indicate a control problem, although some parts at the top of the mast were substantially damaged during the accident.

On 18 April 2015, a Jabiru J250 aircraft, recreational registration 19-7621, collided with terrain near Gympie, Queensland and on 23 May 2015, a Thunderbolt aircraft, recreational registration 19-8601, collided with terrain near Cessnock, New South Wales.

Recreational Aviation Australia (RA-Aus) is responsible for investigating these two accidents. As part of its investigations, RA-Aus requested technical assistance from the Australian Transport Safety Bureau (ATSB) in the examination of data from two multi-function display units recovered from the respective accident sites. To protect the information supplied by RA-Aus to the ATSB and the ATSB's investigative work to assist RA-Aus, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The ATSB successfully recovered data from the avionics devices and provided the data to RA-Aus on 04 May 2016. This completed the ATSB’s support of the RA-Aus investigation.

Any enquiries relating to the accident investigations should be directed to RA-Aus at: www.raa.asn.au.

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The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

Circumstances:

The Air Tractor, VH-OMC, and an Ayres SR2 aircraft were operating in company. The spraying operation had been completed, and both aircraft were loaded with water in order to flush the hoppers and spray equipment during the return flight to St George. After departing the strip, the aircraft deposited the water onto a disused field and then headed for St George, flying at approximately 50 feet above ground level and about 30 metres apart. The pilot of the Ayres S2R saw VH-OMC, which was on his left, suddenly pull up into a climb. He then lost the aircraft from view but moments later saw a cloud of dust rising where it had impacted. Ground witnesses saw both aircraft flying level, approximately line abreast, when the Air Tractor suddenly pulled up steeply, as if to make a turning manoeuvre at the end of a spray run. However, at the top of the pull up the aircraft became inverted and fell to the ground. An inspection of the wreckage revealed no mechanical defects which might have contributed to the accident. The engine was operating at impact.

Significant Factors:

The factors relating to the development of this accident could not be determined.

Circumstances:

The flight was scheduled as a Supplemental Airline (SAL) flight number 421S, but due to the unavailability of a SAL qualified pilot, the flight was rescheduled as a charter flight. Both passengers were booked on airline flights out of Brisbane, one of which was scheduled to depart at 0905. When the pilot and passengers walked out to the aircraft it was raining, and the passengers put their umbrellas and a brief case in the right wing locker. The pilot then closed the locker door before boarding the aircraft. The pilot transmitted a taxiing call to Brisbane Flight Service at 0801 local time. Seven minutes later, he reported lining up on runway 11 and requested an airways clearance. After the aircraft became airborne, witnesses saw it make a left turn and proceed downwind, close to the runway, at about 150 feet above ground level. The landing gear was down, and there was a heavy rain shower in progress at the time at the aerodrome. When the aircraft was abeam the downwind end of the runway, it was seen making a steeply banked turn to the left. As the turn progressed through south, the bank angle became steeper and was estimated by witnesses to be approximately 90 degrees. The aircraft then became inverted and descended into trees. A piece of cleaning rag, found later on the runway, was identified as having been in the left wing locker when the aircraft returned from the previous flight. The rag had apparently fallen from the wing locker after the aircraft became airborne. It could not be determined if the door was incorrectly secured before flight or if it came open of its own accord as the aircraft became airborne. However, it does appear that the pilot noticed the open door soon after take-off and was returning to land and fasten the door when the accident occurred. The resultant delay would have caused the aircraft to arrive in Brisbane late and could explain the pilot's apparent haste to land. Witnesses near the accident site said it was raining very heavily at the time of the accident. This could have caused the pilot to temporarily lose sight of the runway. The aircraft had passed through the extended runway centreline by approximately 200 metres, when the aircraft stalled and struck the trees. There were no mechanical defects found which may have contributed to the development of the accident.

Significant Factors:

The following factors were considered relevant to the development of the accident:

1. The left wing locker door was open in flight for reasons which could not be determined.

2. The pilot was making a close low level circuit and misjudged the turn onto final approach.

3. The pilot used excessive bank during the turn onto final approach and the aircraft stalled.

CIRCUMSTANCES:

"The aircraft was conducting a night DEPARTURE from Runway 36 at Wondai, Queensland. After an apparently normal take-off, it struck the ground 600 metres beyond the end of the runway in a shallow, wings level descent and at high speed. The aircraft was destroyed by impact forces and fire, and five of the six occupants on board were killed.

3. FINDINGS

3.1 The pilot was medically fit, correctly licenced and qualified to undertake the flight.

3.2 There were no significant meteorological conditions existing at the time of the accident, but the night was dark with no moon and no visible horizon.

3.3 There was evidence of influences which could have resulted in the pilot experiencing the effects of fatigue and/or stress at the time of the accident.

3.4 The pilot received no formal ""human factors"" education during his instrument flying training.

3.5 The aircraft became airborne after a take-off roll of about 900 metres and probably reached a height of about 70 feet (21 metres) above the level of the runway before commencing a shallow descent.

3.6 The pilot transmitted an airborne call very soon after lift-off.

3.7 The aircraft speed at impact was approximately 183 knots.

3.8 The aircraft was in controlled flight, wings level and in a shallow descent at impact.

3.9 The aircraft landing gear and flaps were in the retracted position at impact.

3.10 No evidence was found that the aircraft was not capable of normal operation at the time of the accident.

4. FACTORS

The circumstances leading to the development of this accident could not be established conclusively. However, the evidence supports the following as probable factors

4.1 The pilot might not have been aware of the human factors aspects associated with dark night take-offs.

4.2 The pilot could have been influenced by stress and/or fatigue.

4.3 The aircraft was taking off towards dark textureless terrain and no visible horizon.

4.4 By transmitting his airborne call very soon after lift-off, the pilot was not devoting his full attention to flying the aircraft.

4.5 The pilot became disorientated and placed the aircraft in a shallow descent as it accelerated after take-off.

5. SAFETY ACTION

A search of the Bureau's records revealed a number of accidents with circumstances generally similar to this accident. With some exceptions, a pattern emerged in which total pilot experience was moderate to high but hours on type were comparatively low. Pilot age was typically 40-60 years.

The Bureau is undertaking a detailed analysis of these accidents with the aim, among others, of producing a profile of the ""at risk"" pilot. The results of the study will be published in the BASI Journal. Some other aspects of this accident have also been identified as areas which warrant further research. These include

5.1 Instrument rating tests and their effectiveness, particularly in such areas as the transition from visual to instrument flight and test effectiveness when conducted in aircraft of significantly lower performance than that normally flown by the pilot.

5.2 The training methods used in night take-off/no visible horizon situations their effectiveness."

RECCOMENDATIONS:

6.1 It is expected that at least one safety enhancement recommendation will be made as a result of this investigation.

Circumstances:

Witnesses reported seeing the aircraft take off toward the south-west and climb to a height of between 100 and 150 feet above the ground. It then turned right and flew past the witnesses with the wheels about one metre above ground level. As the aircraft crossed the strip, it entered a 15 degree climb to a height of about 150 feet before rolling inverted and diving through trees into the ground. On-site examination showed that the aircraft passed through the treetops at an angle of 80 degrees nose down. The right wing then struck another tree and was torn off. The aircraft attitude at ground impact was about 40 degrees nose down. No evidence was found of any pre-existing defects in the aircraft. Each aircraft seat was fitted with two seat belt systems - an aerobatic harness and a lap/sash type harness. The pilot was wearing the aerobatic harness at impact, but his lap/sash harness was not secured. The rear seat aerobatic harness was firmly fastened on the seat cushion, but the lap sash belt was not secured. This harness consisted of a short lap belt and a one-piece lap/shoulder strap. Tests showed that, if the lap/shoulder strap had been looped over the rear control column, it could have caused a control restriction at about 3/4 right and 3/4 forward control column travel. However, there was no evidence that the strap had fouled the control column in this instance. On a number of occasions during the past few years, the pilot had complained of heart disturbances. He underwent tests but the results were normal. In the week prior to the accident the pilot had reported feeling faint and almost blacking out during flight. He was reported to have planned to consult a medical practitioner on this matter on the Tuesday following the accident. The postmortem examination on the pilot found evidence of a chronic inflammatory disorder of the heart muscle known as myocarditis. This condition can cause disturbances of heart rhythm. However, specialist assessment of the available medical and postmortem information concluded that physical incapacitation of the pilot was a most unlikely factor in the accident. The cause of the accident was not positively determined.

Significant Factors:

The following factor was considered relevant to the development of the accident:

The pilot was conducting an aerobatic manoeuvre at an unnecessarily low height.

At approximately 1740 hours on 11 May 1990 Cessna 500 Astec Eagle aircraft registered VH-ANQ crashed into the eastern slopes of Mt Emerald, Queensland.

VH-ANQ was engaged in operating a charter flight with one crew member and ten passengers. All occupants received fatal injuries as a result of the impact, and the aircraft was destroyed.

History of the flight

Cessna 500 VH-ANQ was operating the Proserpine to Mareeba leg of a charter flight. The aircraft departed Proserpine at 1635 hours on 11 May 1990. It was being operated by Air North Queensland Pty Ltd, a Cairns based charter company.

The charter flight had been organised to transport members of five local government authorities from the Cairns/Atherton Tablelands area to a Local Government Association Conference at Airlie Beach, Queensland. The aircraft departed Cairns on the morning of 10 May 1990 and proceeded to Mareeba, to emplane further passengers, before continuing to the destination, Proserpine. The pilot and passengers remained at the conference facility overnight.

The pilot had submitted a flight plan, prior to departure from Cairns, for both the outbound flight to Proserpine and the return flight to Cairns. Late the following morning he submitted a further flight plan, by telephone, for the return flight to Cairns. The flight plan details, with the exception of the fuel endurance which had been increased to 177 minutes ex Proserpine, were the same as the previously submitted plan. The plan indicated that the flight would follow Instrument Flight Rules (IFR) and depart Proserpine at 1630 hours with a planned cruising altitude of Flight Level 330 (approximately 33,000 feet). The aircraft was planned to track via overhead Townsville then direct to Mareeba with a flight time interval of 68 minutes.

Departure from Proserpine was reported as 1635 hours and the aircraft was cleared to climb to Flight Level 330. The estimated arrival time at Mareeba was 1743 hours. The flight apparently continued normally and at 1726 hours the aircraft was cleared to descend to Flight Level 170 and instructed to call Cairns Approach. (Cairns Approach controls the airspace down to 6,000 feet above mean sea level above Mareeba Airport which has an elevation of 1,560 feet).

On first contact with Cairns Approach, the pilot advised that the aircraft was tracking for Mareeba via the 163 radial at 41 miles (76 kilometres) DME (Distance Measuring Equipment) from Biboohra. (There are no radio navigational aids at Mareeba, the nearest aids for tracking and instrument approach purposes are at Biboohra, about 16 kilometres north of Mareeba). The aircraft was advised to maintain Flight Level 170 but a short time later was cleared to descend to Flight Level 120. The pilot stated that he would not be dosing down the engines at Mareeba and that his estimated departure time was 1750 hours.

At 1735 hours VH-ANQ was cleared to descend to 10,000 feet and one minute later the pilot advised that the aircraft was "approaching over Mareeba and visual". Cairns Approach advised VH-ANQ that there would be a short delay at 10,000 feet and following a request from the pilot gave approval for the aircraft to circle over Mareeba.

At 1740:22 hours, one minute and 14 seconds after the last transmission from VH-ANQ, Cairns Approach instructed the aircraft to descend to 7,000 feet. This transmission, and other subsequent transmissions to the aircraft, went unanswered.

The Civil Aviation Authority commenced Search and Rescue procedures. An aircraft operating in the area reported hearing the signal from an Emergency Locator Transmitter at about 1820 hours. However, the aircraft was unable to determine the exact location of the transmitter because of the adverse weather in the area.

The wreckage of VH-ANQ was ultimately located on the eastern slopes of Mt Emerald, 15 kilometres south of Mareeba Airport, by searching helicopters at 0240 hours on 12 May 1990.

This accident was unusual in that the last report by the pilot indicated that the aircraft was at 10,000 feet and on a track that was 55 kilometres to the east of the accident site. There was no substantiated, and very little circumstantial evidence to suggest what caused the aircraft to descend 6,400 feet and to be displaced a considerable distance to the west of track. As a result, the causal factors associated with this accident remain undetermined.

Circumstances:

The pilot of VH-CXE was flying in company with, but about two miles ahead, of another aircraft flown by his daughter. VH-CXE was observed apparently flying a straight in approach to the sealed Runway 01 at Mt Margaret and to then go around from the approach (there was a 15 knot crosswind from the right at the time). The following aircraft also went around from its initial approach and flew another circuit. Neither occupant of this aircraft saw VH-CXE during the second circuit and a radio query failed to bring any response. A fire was noticed on the western threshold of the dirt cross strip, but this was not associated with VH-CXE. Later, when VH-CXE could not be located, the position of the fire was examined and confirmed as the wreckage of VH-CXE. Investigation revealed that the aircraft had struck the ground in a near vertical nose-down attitude while rotating left. The wreckage had burnt out and the extent of fire damage precluded a complete examination of the aircraft and its systems. However, no evidence was found to suggest that the aircraft was not capable of normal operation prior to the accident. It was established that the landing gear was locked down, the wing flaps were fully extended, and the engine was producing substantial power at impact. It was not possible to determine if the pilot experienced incapacitation prior to the accident.

Significant Factors:

The following factors were considered relevant to the development of the accident:

1. The aircraft struck the ground, probably in uncontrolled flight, for reason(s) which could not be determined.

The pilot was completing an air test following work on one propeller. During the base leg for runway 21 at Perth the aircraft appeared to stall and the pilot did not regain control. It crashed in the back yard of a house in Bassendean causing some roof damage. The out-of-control descent was described as a "falling leaf" indicating the aircraft had little forward speed. Also there was no wreckage trail. The aircraft caught fire on impact. The reason for the loss of control was not determined however, the post-mortem examination of the pilot indicated a possibility of incapacitation resulting from heart failure.

PLT HAD NOT FLOWN AT NGT 21 MTHS.NO STRIP LGTS.DID NOT MONITOR FLT INSTRUMENTS UNTIL JUST BEFORE IMPACT.PLT MOTIVATED TO RESCUE STRANDED PEOPLE.SAR MISSION CO-ORD DIDN'T MAINTAIN OPERATIONAL CONTROL.