Collision with terrain

Grumman AA5A, VH-SZV, 50 Km SW of Coolangatta QLD, 1 December 1984

Summary

As he approached the Macpherson Range the pilot was forced to fly around some hills in order to stay below the cloud base. After crossing a ridge line where the gap beneath the cloud was about 300 feet, the pilot was confronted by a higher ridge. He subsequently advised that the aircraft could not out-climb the terrain and he carried out a controlled entry into the jungle canopy about 200 feet below the top of the ridge. Both wings were torn off however the cabin area came to rest intact.

Occurrence summary

Investigation number 198400052
Occurrence date 01/12/1984
Location 50 Km SW of Coolangatta
Report release date 10/05/1985
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer American Aircraft Corp
Model AA-5
Registration VH-SZV
Operation type Private
Departure point Archerfield QLD
Destination Taree NSW
Damage Destroyed

Cessna T188C, VH-KNL, "Dalkieth" (3.5 kms West of Cassilis) NSW, 29 June 1989

Summary

The aircraft was engaged to spray pasture with insecticide. After a ground inspection of the treatment area, the aircraft was loaded, prior to its first take-off from the strip. Another company aircraft was also operating from the 800 metre long strip. Take-off direction was to the west, with a 2 uphill slope, and a 2 to 3 knot tailwind component. The first aircraft departed without problem. The pilot of VH-KNL, departing some three minutes later, reported that the aircraft's tail was slow to lift off the ground. Some 700 metres from the start of the take-off run, the aircraft encountered soft ground. The pilot selected 20 degrees of flap but this had little effect. The aircraft became airborne and he commenced to dump his load. The aircraft struck a ridge 30 metres from the end of the airstrip, bounced and came to rest on a second ridge 200 metres further on. The pilot reported that the engine had been operating normally, but that he had been late dumping his load, when the aircraft failed to perform. There had been insufficient strip remaining to abandon the take-off. This accident was not the subject of a formal on-site investigation.

Occurrence summary

Investigation number 198902564
Occurrence date 29/06/1989
Location "Dalkieth" (3.5 kms West of Cassilis)
Report release date 09/08/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 188
Registration VH-KNL
Serial number T18803617T
Operation type Aerial Work
Departure point "Dalkieth" NSW
Destination "Dalkieth" NSW
Damage Substantial

Cessna 150-L, VH-RAW, 15 km north of Anningie, Northern Territory, on 3 October 1990

Summary

Circumstances:

The pilot had been operating the aircraft in an aerial spotting role during a cattle muster in generally flat, scrubby terrain. The ambient air temperature would have reached 40 degrees Celsius at the time the crash occurred. The pilot had completed training for a mustering endorsement but had only recently accumulated sufficient flying hours to qualify for issue of the endorsement. A stockman, located about three kilometres distant, had observed the aircraft flying low and after it had disappeared from his view heard sounds which led him to believe that the aircraft had crashed. The aircraft had impacted the ground in a slightly right wing low, steep nose-down attitude. The pilot was contained within the cockpit which had been reduced to non-survivable dimensions. The observed low level of the aircraft, and cattle tracks approximately one kilometre from the impact site, suggest that the pilot was attempting to "push" the cattle at the time of impact.

Significant Factors:

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

1. The pilot was inexperienced.

2. Loss of control at a height insufficient to effect a safe recovery.

Occurrence summary

Investigation number 199000598
Occurrence date 03/10/1990
Location 15 km north of Anningie
State Northern Territory
Report release date 24/04/1991
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Cessna Aircraft Company
Model 150
Registration VH-RAW
Serial number 15072032
Sector Piston
Operation type Aerial Work
Departure point Anningie NT
Destination Anningie NT
Damage Destroyed

Cessna 310-R, VH-KEU, Longreach QLD, 17 March 1988

Summary

The pilot had limited experience in night operations. Until this flight, all night take-offs since obtaining his Command instrument rating had been conducted from airports in well lit areas. This particular take-off was conducted into an area devoid of external visual cues. The aircraft become airborne at the normal speed, and the pilot reported that after lift-off the aircraft was held parallel to the runway until the two-engine best rate of climb speed was acquired. The aircraft was then rotated so that a nose up attitude and positive rate of climb were indicated, whereupon the landing gear was selected up and the landing lights were selected off. The pilot stated that he then checked that the airspeed was 120 knots, the desired climb speed, and was commencing to adjust the throttles when the aircraft struck the ground. The initial propeller strikes indicate that the aircraft had a groundspeed of approximately 136 knots at impact. No faults were found with the aircraft or the aircraft systems that may have contributed to the occurrence. It was likely that the pilot had hurried the after takeoff checks, and had not adequately monitored the attitude of the aircraft.

Occurrence summary

Investigation number 198803442
Occurrence date 17/03/1988
Location Longreach
Report release date 15/02/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Cessna Aircraft Company
Model 310
Registration VH-KEU
Serial number 310R0168
Operation type Charter
Departure point Longreach QLD
Destination Mt Isa QLD
Damage Substantial

Bell 206 L-1, VH-FTV, Port Douglas QLD, 11 February 1988

Summary

The pilot had decided to discontinue the flight due to deteriorating weather conditions. As he was approaching Port Douglas the visibility decreased to the extent that he was unable to maintain visual contact with the coastline. The pilot said that he decreased power to reduce forward speed in an attempt to maintain visual contact, and shortly after this he felt a bump and directional control was lost. The aircraft landed in about 1.5 metres of water some 600 metres from the shoreline. Damage to the tailrotor blades and gearbox, which had separated from the aircraft, indicated that the tailrotor had struck the water before separation.

Occurrence summary

Investigation number 198803432
Occurrence date 11/02/1988
Location Port Douglas
Report release date 28/02/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Bell Helicopter Co
Model 206
Registration VH-FTV
Serial number 45241
Sector Helicopter
Operation type Aerial Work
Departure point Port Douglas QLD
Destination Lockhart River QLD
Damage Substantial

Bell 47 G3B1, VH-WHF, Kilarney Station, Northern Territory, on 15 March 1989

Summary

Circumstances:

After becoming airborne the aircraft was climbed steeply in order to clear a 15 metre high powerline. As the aircraft cleared the powerline the passenger indicated that he wanted to proceed towards the left. The pilot turned the aircraft sharply and, as he did so, he noted a decrease in main rotor rpm. The pilot continued the left turn, until he was pointing towards a clear area, opened the throttle, lowered the collective control and dived towards the ground in an attempt to regain the lost rpm. The attempt was unsuccessful and the pilot elected to land. He raised the nose and increased collective pitch in an attempt to cushion the touchdown. The pilot's actions caused the main rotor blades to enter an overpitched condition and the aircraft touched down heavily.

One skid collapsed and the main rotor struck the fuselage and the ground. No evidence was found that would indicate that the aircraft systems or components contributed to the accident. The steep climb out, to clear the powerline, required the pilot to use most of the excess power available. When the pilot entered a sharp left turn the additional aerodynamic load caused the main rotor rpm to reduce. There was no known reason why the pilot elected to turn abruptly under the particular circumstances. It is probable that the pilot, who had considerable experience on helicopters with low inertia rotor systems, expected the rpm to recover without difficulty. As a result, he misjudged the height and performance change required and was forced to make a rushed decision to convert his attempt at rpm recovery to a landing.

Significant Factors:

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

  1. The pilot carried out an abrupt manoeuvre, which resulted in a decrease in rotor rpm.
  2. The pilot misjudged the performance change required to recover from the low rpm situation.
  3. The excess rotor performance available was insufficient to cushion the landing.

Occurrence summary

Investigation number 198900233
Occurrence date 15/03/1989
Location Kilarney Station
State Northern Territory
Report release date 25/01/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Bell Helicopter Co
Model 47
Registration VH-WHF
Serial number 6763
Sector Helicopter
Operation type Aerial Work
Departure point Kilarney Station NT
Destination Kilarney Station NT
Damage Destroyed

Rockwell S2R, VH-SYQ, Emerald QLD, 8 March 1988

Summary

The pilot was carrying out a spray run near the edge of a cotton crop. He was aware of a powerline crossing his intended flight path and had originally intended to fly over the powerline. At the commencement of the spray run he sighted the pole from which the wires were suspended. The pole was close to the edge of the crop, and assessing that there would be adequate clearance, the pilot decided to fly beneath the wires. However, as he neared the wires he lost sight of them due to poor background. The pilot descended the aircraft as close to the crop as possible in an attempt to sight the wires, and to gain maximum possible clearance. The wheels entered the crop and caused the aircraft to decelerate. The pilot was unable to prevent the aircraft from settling into the crop. The aircraft came to rest after tipping onto its nose and ground looping.

Occurrence summary

Investigation number 198803438
Occurrence date 08/03/1988
Location Emerald
Report release date 22/02/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Rockwell International
Model S-2
Registration VH-SYQ
Serial number 1903-R
Operation type Aerial Work
Departure point Emerald Qld
Destination Emerald Qld
Damage Substantial

Cessna 172-N, VH-SLX, Cravens Peak Station (145 km south-south-west of Boulia), Queensland, on 7 April 1989

Summary

Circumstances:

During the day the pilot, who was at Boulia, had arranged to conduct a charter flight from Bedourie to Boulia. He had earlier been seen drinking beer with a friend in a hotel, but he then conducted the outward leg of the flight, arriving at Bedourie at about 1830 hours. The passengers had expected to make the flight to Boulia the next day, but the pilot was insistent that the flight would take place that evening. The reason for the pilot's decision was not known, however, Civil Aviation Regulations prohibit charter passenger operations at night in single engine aircraft. The aircraft departed at last light. At about 2045 hours an aircraft was heard overhead Cravens Peak Station, which is 115 kilometres west of the track between Bedourie and Boulia. Station lighting was turned on, and the strip was illuminated with vehicle headlights. The aircraft did not have any navigation lights illuminated and was seen to make several low passes before it then disappeared. At about 2130 hours the aircraft reappeared at Cravens Peak, and was seen flying very low, parallel to the strip. The strip was again illuminated with vehicle headlights, but the aircraft disappeared from view in a southerly direction and did not reappear. At the time, a line of active thunderstorms was visible to the north of Cravens Peak, and there was a 25 to 30 knot easterly wind at ground level. Early the next morning, the aircraft wreckage was discovered 730 metres south-south-west of the homestead. It had struck the ground during a shallow descending turn to the right. The sounds of the impact were not heard by station residents, probably due the noise of wind. The reason for the gross navigational error could not be established, but the pilot was subsequently found to have a high blood alcohol reading, which could have significantly impaired his ability to conduct the flight safely. There were no aircraft 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 pilot attempted an operation which was in contravention of published regulations.

2. The pilot became lost during the flight.

3. The pilot had consumed alcohol before the flight, which could have impaired his ability to conduct the flight safely.

Occurrence summary

Investigation number 198903764
Occurrence date 07/04/1989
Location Cravens Peak Station (145 km south-south-west of Boulia)
State Queensland
Report release date 16/02/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172-N
Registration VH-SLX
Serial number 17267635
Sector Piston
Operation type Charter
Departure point Bedourie QLD
Destination Boulia QLD
Damage Destroyed

Cessna 310-R, VH-DZH, 90 km NNE Maralinga SA (Lat 29o 22.2'S, Long 131o 52.8E ), 9 June 1988

Summary

The Cessna 310 and a Cessna 402 from the same company had been chartered to uplift a group of people from Emu. Emu lies at the eastern edge of the Great Victoria Desert, and is not equipped with radio navigation aids or aerodrome lighting. Arrangements had been made to light a signal fire and lay a flare path in case either aircraft arrived after the end of daylight, estimated to be 1818 CST on the day. The flights to Emu were originally planned for the following morning, but were brought forward by the charterer at short notice. This required rescheduling and reconfiguring of the aircraft, with the cumulative effect that they were both running late on the revised schedule. Each aircraft planned a refuelling stop at Ceduna, and while inbound to Ceduna, the pilot of VH-DZH requested a third company pilot on the ground at Ceduna to submit a flight plan on his behalf for the return flight to Emu. This plan showed a flight time interval to Emu of 72 minutes, and a fuel endurance of 300 minutes. The Ceduna weather consisted of broken low cloud associated with showers near the coast, and strong southwesterly winds. Conditions to the north of Ceduna were fine, with the strong winds abating approximately half way to Emu. VH-DZH landed at Ceduna approximately one hour before the C402. During a hurried turnaround, the pilot was observed to run from the FIS building to his aircraft, taxy out quickly, and make a rapid DEPARTURE and steep climbout. The pilot reported that he was tracking 315o on climb to 8500 ft. A considerable number of communications then ensued on a non-FIS VHF frequency between the pilot of VH-DZH, and the pilot of the C402 who was still inbound to Ceduna. During these exchanges the pilot of VH-DZH became aware that the track of 315oM he was following from the flight plan was incorrect, and should have been 334oM. The pilot of VH-DZH also enquired about the altitude of Emu aerodrome, and was given the correct altitude of 500 ft amsl. The pilot of VH-DZH was a Director and Operations Manager of the company, and the exchanges covered a variety of business matters, besides the flights to Emu. At times the exchanges included the third pilot, who by then was en route to the east. At 1639 the pilot advised FIS that he was climbing to cruise at a non-quadrantal altitude of 10,000 ft. There was one position report to be given during the flight, and this was 100 nm Ceduna (185 km) where the track crossed the transcontinental railway line. He reported passing the position at 1657, 2 minutes later than flight planned, and gave an ETA for Emu of 1739, 4 minutes later than flight planned. As the C402 pilot had previously operated into Emu and the pilot of VH-DZH had not, he suggested to the pilot of VH-DZH that he obtain a fix at the Wilkinson Lakes between the railway line and Emu, then track to Lake Meramange approximately 10 nm (18 km) north-northwest of Emu and backtrack from there to Emu. Exchanges between the two pilots continued until the C402 landed at Ceduna. At 1721 the pilot reported on descent to Emu, and at 1740 reported in the circuit area and cancelled Sarwatch. This was the last communication between the pilot and FIS. The C402 departed Ceduna at 1743, and the pilot of this aircraft soon began to receive communications from the pilot of VH-DZH on the non-FIS frequency. At approximately 1752 the pilot of VH-DZH said that he could not find Emu and the C402 pilot suggested he climb to 10,000 ft and find Lake Meramange on his radar. However, he said he still had enough light but thought he must have gone too far north and would head towards the south, diverting back to Ceduna if he did not sight anything. The C402 pilot subsequently advised that the signal fires had been lit, and at approximately 1835 the pilot of VH-DZH reported sighting a fire and going to investigate. His last transmission to the C402 pilot was to the effect that he thought he had found Emu. Ground witnesses 43 nm (80 km) south of Emu reported later that at approximately 1840, when it was completely dark, an aircraft coming from the north or north-northeast had overflown their roadside campfire. The aircraft then orbited their position and they flashed torches at the aircraft. The aircraft's landing lights flashed off and on in apparent response. The aircraft then made a left-hand turn and overflew them again from the east at very low level with landing lights on. They had then doused their fire as the aircraft flew off to the southeast, since they knew of the flights to Emu and were concerned that the pilot of this aircraft might mistake their campfire for a signal fire at Emu. They did not see or hear the aircraft again. Wreckage of the aircraft was subsequently located 1.5 nm (3 km) from the campsite. An on scene examination showed that the aircraft had first hit a tree on top of a sand dune at an elevation of 650 ft amsl, before striking other trees and impacting the base of a large tree. The attitude at first impact was 5o left wing down, and in a shallow descent. The disintegration pattern was consistent with that of a high performance twin-engined aircraft colliding with obstructions and the ground while both engines were operating normally. A detailed examination of the wreckage did not reveal any defects or anomalies that may have contributed to the accident. The radio navigational equipment carried by the aircraft included dual ADF, and DME, and the pilot was properly rated for the use of these aids. The rated range of the Ceduna NDB over land is 110 nm by day (203 km) and 85 nm by night (157 km). At 10,000 ft the rated coverage of the Ceduna DME should have been 90 nm (167 km). The pilot was in regular IFR flying practice, and was a Director and Operations Manager of the charter company. Investigation revealed that the 19o track error on the flight plan had occurred due to a misalignment between the Tarcoola and Port Augusta WAC charts, when they were butted together by the third company pilot to measure the track. The track however, was correctly drawn on the chart. The pilot of VH-DZH did not have a Tarcoola chart, and the planning pilot had left his own copy along with the flight plan and other documentation at the FIS unit where they were subsequently collected by the pilot of VH-DZH. The pilot who prepared the flight plan had arrived at the aerodrome later than he had intended, and this additional task made him concerned about keeping his own bank run schedule which required a DEPARTURE from Ceduna at 1600. The planned time intervals to Emu were also incorrect, as the planning pilot had lost the wind grid from his navigation computer and he assumed a tailwind component of 10 kt whereas there was a headwind component of 3 kt on the correct track and 13 kt on the incorrect track. The correct time interval from Ceduna to Emu on the correct track should have been 77 minutes, compared with the incorrect interval of 72 minutes planned on the wrong track. What navigational adjustments may have been made by the pilot when he learned of the incorrect track could not be established. It was determined that he learned of the mistake prior to the 100 nm Ceduna position, and this should have permitted interception of the correct track by ADF and DME. FIS was not advised that there was to be any change of track from 315oM. Although analyses of several alternative tracking and navigational possibilities were made during the investigation, it was not possible to define an approximate ground track of the aircraft up to the time the pilot cancelled Sarwatch. It is clear that the pilot had not found Emu when he cancelled Sarwatch, and had searched for another hour without finding it. It was also not possible to reconstruct the ground track of the aircraft during that last hour. No witnesses at Emu reported sighting or hearing the aircraft at any time, and it was established that the flares and signal fires were not lit until after last light. The witnesses 43 nm south of Emu reported that when first heard, the aircraft had approached from a northerly or north-northeasterly direction. In turn the pilot, for reasons which were undetermined, apparently believed he was north of Emu, and had advised the C402 pilot that he would head south. Although the witness reports were consistent with the pilot carrying out that course of action just prior to the accident, the aircraft had not been seen or heard at Emu and the movements of the aircraft in the intervening hour could not be established. The flight plan ETA for Emu from Ceduna would have been 1740 had forecast wind and correct track been used. The pilot gave his last ETA for Emu as 1739 and actually reported in the circuit area at 1740. It was established that the pilot normally descended at 500 fpm so that the 18 minutes allowed for the descent were not unusual given the cruising level, and altitude of Emu. Application of the wind component experienced by the C402 en route to Emu to the flight of VH-DZH produced a slightly shorter total time interval to Emu. This could mean that the aircraft may have passed Emu in the late part of the descent. However, again, witnesses at Emu did not report hearing or seeing the aircraft. The analysis of all the navigational aspects of the flight therefore, did not allow the position of the aircraft to be estimated at the time that Sarwatch was terminated. The night was very dark when the pilot overflew the campsite at low altitude on the second pass. The single light source from the campfire would not have provided sufficient visual information for the pilot to judge his height above ground level. The pilot then flew off to the southeast at the same attitude and evidently then continued turning left in an effort to relocate the campfire, unaware that it had been extinguished by the alarmed ground witnesses. A turn overshoot occurred to the extent that the aircraft crashed on a heading of 204?M whereas the pilot could have expected to sight the fire on a heading of approximately 270?M. This suggests that the pilot was not referring to the flight instruments at the time, and did not notice the 70? heading discrepancy or the shallow descent, which was occurring when the impact with the tree occurred. It is unlikely that fatigue was a significant factor in the accident. There had been no change in the pilot's normal routine in the days prior to the accident, and he apparently had no difficulty in working long hours as a matter of course. Research shows that the effects of fatigue on performance typically occur after 17 hours of wakefulness, and this pilot had been continually awake for 14 hours at the time of the accident. It was established that the pilot was accustomed to running his business from the aircraft during flight.This included the completion of paperwork, frequent calls to other aircraft of the same organisation and the use of a cellular telephone. The steady stream of communications with his other two pilots on this occasion is consistent with this pattern, although it was not established whether the telephone had been used. It was evident from his previous flying activities that normal inflight watch procedures were often displaced in favour of handing day-to-day business requirements. Operations into the remote areas of Australia require sustained concentration on navigation unless a pilot is property familiar with the particular area of operation. On this occasion the pilot had not previously been to Emu, he would have experienced glare from the setting sun, while in the month of June the long twilight shadows from the sand dunes, undulations and vegetation can present a very difficult panorama to interpret. The flares and signal fires at Emu were not lit until dark, but when they were lit they were visible to the C402 pilot from a distance of 60nm (111km). The C402 pilot remained at his cruising altitude until he sighted the fires, whereas the pilot of VH-DZH had descended before dark and before the fires at Emu had been lit. There was also not suggestion from the exchanges between the two pilots that the pilot of VH-DZH had climbed above the general altitude from which his search had been initiated. The pilot cancelled Sarwatch close to his ETA, but then continued to search for Emu for another hour without notification to any airways unit. Such behaviour was reportedly out of character for the pilot, and the last 22 minutes of the search were carried out in complete darkness. In the light of his ample fuel reserves, his decision to spend some time searching for his destination in daylight was understandable given that he believed he was in the vicinity. In continuing to search for such a long period however, it is likely that the pilot was influenced by personality factors. It was reported that the pilot had a determined personality and disliked failure. In the circumstances, the C402 pilot already knew that he had not found Emu, and a return to Ceduna would require re-establishment of communications with FIS and a subsequent arrival at Ceduna without passengers. The alternative to a return to Ceduna was to climb and follow the suggestion of the C402pilot. The flight had been running late, and a flight plan containing significant inaccuracies had been prepared by another pilot. A hurried turnaround at Ceduna was apparently motivated by a desire to reach Emu prior to the end of daylight. Detailed attention to navigation evidently suffered due to a diversion of the pilot's attention onto other matters during the flight, and a descent was carried out in relation to the Emu ETA rather than following the suggestion of the C402 pilot of tracking to Lake Meramanqe then backtracking to Emu. When unable to locateEmu the pilot commenced a search which was extended past the end of daylight into night conditions, and eventually an isolated campfire was sighted. Believing that the campfire may have been associated with signal fires which he knew had been lit at Emu, the pilot manoeuvred the aircraft at a very low level while evaluating his discovery. The attempt to manoeuvre the aircraft safety without colliding with the ground or obstructions when in such close proximity to the ground on a dark night would be difficult. If flown solely by reference to flight instruments, then the manoeuvres were conducted approximately 1000ft below the IFR lowest safe altitude while the single light source from the campfire could not have provided sufficient visual information for the pilot to judge his height above the ground.

Occurrence summary

Investigation number 198800718
Occurrence date 09/06/1988
Location 90 km NNE Maralinga SA (Lat 29o 22.2'S, Long 131o 52.8E )
Report release date 21/12/1988
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Cessna Aircraft Company
Model 310
Registration VH-DZH
Serial number 1657
Operation type Charter
Departure point Ceduna SA
Destination Emu SA (Lat 28o 37'S, Long 132o 11'E)
Damage Destroyed

Hughes 269-C, VH-HFU, 50 km south-east of Papunya, Northern Territory, on 17 May 1990

Summary

Circumstances:

The pilot was making an approach to a cathode protection point on the pipeline to set down the engineer. The selected alighting point was on the slope of a saddle and the aircraft descended until the right skid was on the ground. As he lowered the collective to rest the left skid, he felt that the slope was excessive for a landing. Accordingly, he flew the helicopter up to an in-ground-effect (IGE) hover at about four to five feet and made a left pedal turn through about 90 degrees to move to a more level site further downhill. Seconds later after starting to hover-taxi, the pilot reported a shudder and noticed that the main rotor RPM was decreasing. Despite the introduction of power without collective input, the helicopter continued to descend. The pilot was unable to prevent the helicopter touching down and, after a series of skips and touches, the helicopter crashed in a nose-down attitude and came to rest on its right side. Both occupants exited without assistance through the pilot's side door. The pilot later reported that he felt the throttle travel to its full limit and believed that he was not getting the full power output from the engine. Subsequent engineering investigation of the aircraft did not reveal any anomalies or faults that could have contributed to the accident. Further investigation indicated that the pilot had had a poor night's sleep due to apprehension about the forthcoming tasks for the day. In addition, he had been concerned about family matters due to his unaccompanied move to gain employment. At the time of the accident, he had been flying for about seven hours. The nature of the operation undertaken with frequent landings at difficult sites is conducive to skill fatigue. Skill fatigue is defined as the deterioration in performance caused by work that demands persistent concentration and a high degree of skill. It is an insidious phenomenon associated with failure of memory, judgement, integrating ability and presence of mind. Its effects may occur in conjunction with, and be accentuated by, other factors such as sleep loss. The prevailing conditions at the site chosen for landing were such that the helicopter was facing downwind after the completion of the pedal turn and was in a high power and weight configuration. It is possible that at some stage during the turn the main rotor rpm drooped. The pilot did not become aware that the rotor was in an overpitched condition until the rotor rpm had drooped so low that full throttle would not have been sufficient to prevent ground contact. The nature of the terrain was such that a safe landing was not possible under the prevailing conditions.

Significant Factors:

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

1. The pilot was probably suffering from skill fatigue.

2. The pilot did not realise that he was close to the limits of operation of the helicopter under the prevailing conditions.

3. The pilot probably overpitched the rotors at a height insufficient for recovery in an attempt to regain control of the helicopter.

4. The terrain was such that a safe landing was not possible.

Recommendations:

1. That the Bureau of Air Safety Investigation and the Civil Aviation Authority prominently publish the circumstances and causes of this accident for the education of helicopter pilots.

Occurrence summary

Investigation number 199000587
Occurrence date 17/05/1990
Location 50 km south-east of Papunya
State Northern Territory
Report release date 10/12/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Hughes Helicopters
Model 269
Registration VH-HFU
Serial number 900955
Sector Helicopter
Operation type Aerial Work
Departure point Tylers Pass NT
Destination Glen Helen Lodge NT
Damage Substantial