Collision with terrain

Robinson R22 Beta, VH-HMR

Summary

This occurrence was investigated in 1998, and a summary report was released. The ATSB received new and significant information about this occurrence in 2004 and initiated further investigation. As a result, the ATSB has revised the summary and reissued the report as follows:

The pilot reported that he disembarked from the helicopter, leaving the engine running and the rotors turning, to converse with a stockman. He was returning to the helicopter when he heard the helicopter's engine and main rotor RPM increasing. The pilot attempted to reach the throttle control and was at the right skid before being forced to dive away as the helicopter became airborne. The helicopter flew into the ground about 5 m from its lift off point and was destroyed. There were no injuries. The wind conditions were reported by the pilot as being light and variable.

The pilot reported that he had set the engine throttle to 75%, selected the governor off, and used the cyclic and collective friction to secure the flying controls. The collective was also fitted with a strap to help secure its position but the pilot could not recall if it was deployed. The operator reported that photos taken after the occurrence indicate that the governor was selected on and the collective strap was not deployed. The circumstances of the occurrence are consistent with inadvertent raising of the collective control.

Occurrence summary

Investigation number	199803826
Occurrence date	14/09/1998
Location	Myroodah Station, (ALA)
State	Western Australia
Report release date	28/06/2004
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	Robinson Helicopter Co
Model	R22
Registration	VH-HMR
Serial number	1022
Sector	Helicopter
Operation type	Aerial Work
Departure point	Myroodah Station, WA
Destination	Myroodah Station, WA
Damage	Destroyed

Cessna A150M, A1500662

Safety Action

At the time of the investigation the Civil Aviation Safety Authority was conducting an investigation into aspects relating to the pilot's licence, training and employment.

Summary

A Cessna 150, VH-FPS, was being used to muster sheep near Dalgety Downs Station. The pilot was communicating by radio with the ground party and had called in one of the party to help with a mob of sheep. A ground party member reported that the aircraft flew past him at about 80-100 ft above the ground before commencing a sharp turn to the right. During the turn the aircraft descended into the ground and caught fire. The pilot received fatal injuries. There was no evidence that the aircraft or engine had been affected by any mechanical fault before colliding with the ground.

About two months prior to the accident, the pilot's employer had arranged for the pilot to receive mustering endorsement training, which included low flying. Subsequent to the accident, the company that conducted the training reported that they had verbally advised the employer that the mustering training could not be carried out, and that only the low-flying portion of the endorsement had been completed. The documentation provided by the training company to the operator indicated that the pilot had only been given a low flying approval. The pilot's low flying training had been conducted in FPS. A review of the aircraft documentation indicated that the hours flown during the training period had been insufficient to permit both the completion of the low flying and stock-mustering training. There was no evidence to indicate that the pilot had completed aerial stock-mustering training.

Approval to conduct aerial stock mustering requires certification that an applicant has completed both low flying and aerial stock mustering training. The approval certificate at appendix II of Civil Aviation Order (CAO) 29.10 was designed to indicate that the applicant pilot had successfully completed the required training, and qualified to conduct aerial stock mustering. The approval certificate had two sections. The first section was to record that the required low flying training had been completed. The second section was to record that mustering training had been completed and the applicant was competent to conduct mustering operations.

The low flying approval certificate issued by the training organisation may have been inappropriate because it was not derived from the CAO current at the time, and because it recorded that the pilot had only undergone low flying training. There was no reference to stock-mustering training on the certificate used. Therefore, the certificate could not have been considered a stock-mustering approval. It appears that the operator did not review the CAO under which the low flying approval was awarded. Had he done so, it would have been evident that stock-mustering endorsement training had not been certified and that the pilot was not qualified to conduct stock-mustering operations.

The investigation could not determine why the aircraft descended into the ground during the turn.

Occurrence summary

Investigation number	199803584
Occurrence date	02/09/1998
Location	Dalgety Downs Station, (ALA)
State	Western Australia
Report release date	10/09/1999
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-FPS
Serial number	VH-FPS
Sector	Piston
Operation type	Aerial Work
Departure point	Dalgety Downs Station, WA
Destination	Dalgety Downs Station, WA
Damage	Destroyed

Grumman American Aviation Group GA-7, VH-WPX

Summary

The aircraft was outbound from Adelaide on the first sector of a daily bank run and was being operated at night under the Instrument Flight Rules. The pilot reported that the township lights of Minlaton were visible during the descent, and the runway lights were clearly visible from a distance of about 12 NM. The pilot joined the circuit on a downwind leg for runway 15 and said that the runway lights were visible on both downwind and base legs. Shortly after turning final, at a height of approximately 400 ft, the pilot initiated a missed approach after losing sight of the runway. The runway lights were visible as the aircraft passed overhead the aerodrome, as were the lights of a motor vehicle passing the southern end of the runway. The pilot elected to attempt another approach for runway 15, with the option of landing on runway 33, if the second approach was unsuccessful.

A second circuit was flown at about 800 ft, with the runway lights remaining in sight on the downwind and base legs. Shortly after turning final the aircraft entered patchy low cloud that was obscuring the runway lights for brief periods. The pilot reported that he was in the process of commencing a second missed approach when he regained visual contact. He reduced power but again lost contact. While searching for the runway lights he initiated a missed approach but felt the main wheels touch down. He immediately closed the throttles and allowed the aircraft to roll to a stop.

The aircraft had touched down in a paddock approximately 800 m before the runway threshold and had rolled normally on its landing gear for about 600 m. However, the aircraft was substantially damaged when it entered a lightly timbered area at moderate speed. The pilot sustained minor injuries.

The Area 50 forecast prepared by the Bureau of Meteorology, valid from 0130 to 1430 Central Standard Time, indicated that the aircraft would be operating to the west of a trough moving through the area. Isolated showers and drizzle, together with broken low cloud on the coast and western slopes, were forecast until 1130. Isolated fog patches were forecast until 1030.

The terminal area forecast (TAF) issued for Minlaton at 0434 for the period 0530 to 1730, predicted a light south-westerly wind and rain showers. Broken cloud cover was forecast at a height of 2,500 ft, with a few lower patches at 1,200 ft, together with a visibility greater than 10 km. The forecasting officer preparing the TAF considered the possibility of low stratus, fog or drizzle affecting aircraft operations into Minlaton. However, each was discounted on analysis of the synoptic situation and on other available information. The Minlaton TAF was reviewed at 0600 but it was considered that no amendment was required. The Bureau prepares regular aerodrome forecasts for Minlaton, without the benefit of local weather observations.

The pilot subsequently lost visual contact with the runway lights at low altitude when the aircraft entered a localised area of cloud or fog, at a height lower than forecast. The aircraft had then inadvertently contacted the ground while the pilot was initiating a missed approach.

Occurrence summary

Investigation number	199803049
Occurrence date	07/08/1998
Location	Minlaton, (ALA)
State	South Australia
Report release date	15/07/1999
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	Grumman American Aviation Corp
Model	GA-7
Registration	VH-WPX
Serial number	GA7-0104
Sector	Piston
Operation type	Charter
Departure point	Adelaide, SA
Destination	Minlaton, SA
Damage	Substantial

Mooney M2OJ, VH-DXT

Summary

The pilot of the Mooney M20J aircraft had planned to take one of his employees from Jandakot to Laverton via Melita Station, where he intended to deliver a small quantity of equipment. The aircraft arrived overhead Melita Station at about 1730 Western Standard Time, approximately 2 hours and 20 minutes after departure. A station hand reported that the aircraft flew over the upwind threshold of the airstrip at a low level and heading in a southerly direction. The aircraft then appeared to fly a downwind leg of a normal circuit before it banked sharply to the left onto an apparent final approach. The station hand then saw the aircraft fly quite close to the ground for about half the length of the airstrip, before adopting a nose-high attitude. The engine noise then increased, although it sounded laboured. When the aircraft was about 100 ft above the ground, he heard the engine noise stop. He then saw the aircraft pitch nose-down and impact the ground in a near vertical attitude. The aircraft was destroyed by the impact and the occupants received fatal injuries. There was no fire.

The aircraft wreckage was located 270 m beyond the northern end of the airstrip and 20 m to the right of the extended centreline. The landing gear was extended, and damage evidence indicated that the propeller was not under power at impact. The flaps were extended; however, their exact setting at impact could not be determined.

The fuel boost pump switch was found in the "off" position. However, it could not be established if the switch was in that position before the accident. The engine-driven fuel pump was damaged during the impact and the investigation was unable to determine if it was functioning correctly prior to the accident. If the engine-driven fuel pump had failed while the fuel boost pump switch was turned off, the engine could have failed due to fuel starvation.

The aircraft was fitted with an emergency locator transmitter (ELT) certified to US Federal Aviation Administration Technical Standard Order (TSO)-C91. Although it appeared to be correctly mounted and connected, The ELT did not activate at the time of the accident. Its instrument panel mounted switch was selected to "arm" and the ELT unit's switch was selected to "auto". The investigation could not determine why the ELT had not operated during the accident. When tested during the investigation, it operated normally.

The Melita Station airstrip, with a useable length of approximately 900 m, was adjacent to the homestead and was aligned approximately north-south. There was no airstrip lighting at Melita; however, runway lighting was available at Laverton.

At the time of the accident, the wind was calm and there was no cloud. The temperature was about 15 degrees Celsius. The station hand stated that although it was twilight, he was able to carry out his tasks without artificial lighting. Airservices Australia advised that the end of daylight on the day of the accident was 1733. The aircraft's flight manual indicated that the aircraft was equipped for night flight.

The pilot held a private pilot licence and a night visual flight rules rating, and was endorsed on the aircraft type. During his aviation medical examination, the pilot indicated that he had a significant family cardiac history. The post-mortem examination established that one of the pilot's coronary arteries was approximately 90 per cent blocked.

The aircraft departed Jandakot with both fuel tanks full. Each tank contained approximately 121 L of useable fuel. Reference to the aircraft's flight manual indicated that fuel usage for the flight should have been between 90 L and 100 L. The pilot's operating handbook (POH) warned that if the selected fuel tank contained less than 30.3 L of fuel, take-off manoeuvres and prolonged sideslips may cause a loss of engine power. Had the engine been drawing fuel from only one tank during the flight from Jandakot to Melita, there would have been approximately 20 L to 30 L of fuel remaining in that tank on arrival at Melita. The nose-high pitch attitude that the aircraft was seen to adopt shortly before the accident might have caused a loss of engine power had the selected fuel tank contained less than 30.3 L. Immediately after the impact, fuel was seen flowing from the aircraft and a strong smell of fuel was evident for some time afterwards. The aircraft's weight and centre of gravity were estimated to have been within the prescribed limits at the time of the accident.

The loss of control during the apparent go-around was consistent with the engine losing power and the aircraft stalling at a height from which recovery was not considered to be possible. The POH warned that the aircraft might lose up to 290 ft of altitude during a stall at maximum weight.

The investigation was unable to establish the reason for the engine failure and did not identify any pre-existing aircraft defects that might have influenced the circumstances of the accident. The significance of the effects of the pilot's medical condition could not be determined.

Occurrence summary

Investigation number	199802458
Occurrence date	29/06/1998
Location	15 km S Leonora, Aero.
State	Western Australia
Report release date	27/08/1999
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	Mooney Aircraft Corp
Model	M20
Registration	VH-DXT
Serial number	24-1081
Sector	Piston
Operation type	Business
Departure point	Jandakot, WA
Destination	Melita Station, WA
Damage	Destroyed

Cessna 337A, VH-YGM, 1 km west-south-west of Bundaberg Aerodrome, Queensland

Summary

The aircraft crashed shortly after taking off from runway 25. It caught fire and was destroyed. Witnesses reported that the aircraft commenced the take-off roll with the rear propeller not rotating.

Wreckage examination confirmed that the rear engine was not operating at impact. No fault was found which would have prevented normal operation of that engine and no fault was found in any other system or component of the aircraft.

Occurrence summary

Investigation number	199802140
Occurrence date	07/06/1998
Location	1km WSW Bundaberg, Aerodrome
State	Queensland
Report release date	09/03/1999
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	337
Registration	VH-YGM
Serial number	3370401
Sector	Piston
Operation type	Private
Departure point	Bundaberg, Qld
Destination	Ballina, NSW
Damage	Destroyed

Cessna 210R, VH-IOR

Significant Factors

The planned route was over mountainous terrain, in adverse weather conditions, and at an altitude above the forecast freezing level.
Moderate to severe turbulence had been forecast in the vicinity of the Snowy Mountain ranges and the meteorological conditions were conducive to the formation of mountain waves.
At the time radar contact with the aircraft was lost, the pilot was attempting to climb the aircraft to an altitude of 10,000 ft and appeared to be flying it at a lower than normal climb speed. The reason for the observed loss of climb performance as the aircraft approached 9,000 ft could not be positively determined.
The aircraft impacted the ground in an attitude consistent with a loss of control. The reason for the loss of control could not be established.

Analysis

The circumstances of this occurrence are consistent with the aircraft being flown at the limit of its performance capabilities, in the prevailing weather conditions. In addition, the reported medical condition of the pilot and the stress associated with operating an aircraft in such weather conditions, requires balanced consideration of the possibility of pilot incapacitation being a factor in the accident.

The Area 21 forecast indicated that the first part of the flight could be conducted clear of cloud during the climb and cruise, with the cloud tops forecast to extend to 8,000 ft in the area through which the aircraft was flying. The recorded radar data indicates that the aircraft was not significantly affected by airframe ice on initially reaching the planned cruising altitude of 10,000 ft.

However, the aircraft did appear to encounter icing conditions as it approached Cooma. The progressive reduction in aircraft groundspeed and the minor altitude variations from the aircraft transponder are consistent with the aircraft operating in convective cloud and accumulating airframe ice. A short time later, the aircraft was observed on radar to conduct a descending orbit and the pilot indicated that he was diverting to Cooma for a landing.

It is likely that during the descent, the aircraft broke clear of cloud and the pilot considered that he was able to continue towards his planned destination. The pilot was familiar with the route sector being flown and would have been aware of the height of terrain in the vicinity. It is unlikely that the pilot would operate the aircraft in cloud, below the lowest safe altitude and continue to fly towards rising terrain.

The apparent improvement in the stability of the radar recorded descent profile also suggests that the pilot had established visual reference during the latter stages of the initial descent from 10,000 ft. The radar recorded data, particularly the groundspeed that the aircraft achieved after levelling off, supports the pilot's report of having "unloaded" the airframe ice. It is likely that the aircraft was no longer operating in cloud and was not significantly affected by airframe ice at this time. The pilot had also commented about being able to get over the cloud at Kosciusko which further suggests the aircraft was established clear of cloud at this time.

Approximately eleven minutes before the accident the pilot reported that he had commenced climbing to 10,000 ft. The aircraft subsequently reappeared on radar and was observed to take up a track that would pass directly overhead Mt Jagungal, in conditions that were conducive to the formation of mountain waves and the forecast probability of occasional severe turbulence. The reported weather conditions at the time of the accident suggest that Mt Jagungal was probably covered by cloud and the pilot may have been unaware of his proximity to the mountain peak.

Based on the reported wind direction and strength, the radar-recorded low groundspeed suggests that the aircraft was climbing at a lower-than-normal airspeed. This would have provided the pilot with a reduced safety margin above the stalling speed. The apparent reduction in climb performance as the aircraft approached 9,000 ft can be attributed to the aircraft flying into the descending air associated with mountain wave activity. Had the pilot elected to level out at this altitude, it would be reasonable to expect that a measurable increase in groundspeed would be associated with the setting of a flight attitude for straight and level flight.

The witness sighting of the aircraft a short time before the accident indicates that at this point, the aircraft was established clear of cloud, but with a broken layer of cloud below. It was not possible to determine if the aircraft was significantly affected by airframe ice at the time of the accident. The presence of any ice on the airframe would have further increased the aircraft's stalling speed and further reduced the margin for any airspeed fluctuations due to turbulence.

It is possible that while attempting to continue climb to 10,000 ft the aircraft encountered moderate to severe turbulence. The unpredictable fluctuation in airspeed could have resulted in an inadvertent stall. The aircraft departed controlled flight immediately prior to the accident and impacted the ground at high speed in a near vertical attitude, consistent with an uncontrolled spiral dive. The reason for the loss of control could not positively be established.

Furthermore, the possibility of pilot incapacitation cannot be excluded as a contributing factor in the occurrence. The reported operation of the aircraft engine to the point of impact, together with the uncontrolled nature of the descent, indicates that there had been no effective response initiated to counter the rapid descent of the aircraft.

Summary

The pilot of the Cessna 210 was to be accompanied by five passengers on a flight from Merimbula to Albury. A flight notification was submitted by telephone to the Airservices Australia regional briefing office which indicated that the aircraft would be operating under the instrument flight rules and would track to Albury via Cooma and Corryong at 10,000 ft. The pilot obtained a pre-flight briefing from the Airservices Australia automated pilot briefing system (AVFAX) and selected a product code that provided weather forecasts and operational information for aviation meteorological forecast Area 21.

The Area 21 forecast was applicable for the sector of the flight from Merimbula to approximately 30 NM east of Corryong. At that point the aircraft would enter the eastern part of the adjoining Area 30. The pilot did not order any briefing products for Area 30 from the AVFAX system, which would have included information for his destination aerodrome. No information was requested from the briefing officer during the telephone submission of the flight plan and it was not possible to establish if the pilot had obtained an Area 30 or destination aerodrome forecast from alternative briefing sources. It was reported however, that prior to departing Merimbula the pilot had telephoned a family member to inquire about the prevailing weather conditions in Albury.

The forecast for Area 21 indicated that there would be significant cloud extending up to 8,000 ft over the Snowy Mountain ranges, with some isolated tops to 11,000 ft in the far south of the area. Moderate icing was forecast in the tops of cumulus cloud. The freezing level was forecast to be at 6,000 ft in the south. A hazard alert had been issued for occasional severe turbulence below 10,000 ft over, and to the east of, the ranges. A westerly wind of 30 knots was forecast at the pilot's intended cruise level.

The conditions forecast for Area 30 were similar to those for Area 21. Broken cumulus cloud tops were forecast to extend to 10,000 ft with broken altocumulus/altostratus from 8,000 to 20,000 ft in the east of the area. Moderate icing was forecast in cloud above the freezing level and areas of isolated severe turbulence near the ranges below 10,000 ft. The cloud forecast for Area 30 indicated that flight along the proposed route could possibly require flight in cloud, above the forecast freezing level. The aircraft was not equipped for flight in known icing conditions.

The aircraft departed Merimbula at 1200 Eastern Standard Time and the pilot reported to flight service that he was tracking for Cooma and was on climb to 10,000 ft. Although the aircraft would not enter controlled airspace until just before Albury, an en-route radar controller would provide the pilot with a flight information service from 30 NM south-east of Cooma. The pilot was issued with a transponder code for radar identification and was given frequency change instructions. Flight service also passed information to the pilot on a hazard alert that had been issued for Albury aerodrome, due to cloud at 1,200 ft above ground level, which had not cleared as had been forecast.

As the aircraft approached top of climb it appeared on the en-route controller's radar display. The radar return from the aircraft's transponder indicated that the aircraft had levelled off at 10,100 ft and its ground speed was observed to steadily increase from 78 knots and then stabilise for a short period at approximately 140 knots. The ground speed was then observed to commence a gradual reduction, which was accompanied by some minor variations in the radar-recorded transponder altitude.

At 1233 the pilot reported overhead the Cooma non-directional beacon at an altitude of 10,000 ft. The radar-derived groundspeed was reducing through 110 knots at this time and continued to reduce at a constant rate, before stabilising at approximately 95 knots.

When the aircraft was 8 NM northwest of Cooma the controller observed the pilot to be conducting what appeared to be a descending turn to the right. The controller requested that the pilot confirm that aircraft operations were normal and the pilot responded that "operations are not normal" and indicated that he was diverting to Cooma for a landing. The recorded radar data indicated that the initial stage of the descent was uneven, with erratic rates of descent and some increases in altitude. The final part of the descent was conducted at a stable rate.

A short time later, the pilot advised the controller that he was tracking 310 degrees at an altitude of 7,500 ft and that the descent had been necessary due to an accumulation of airframe ice. The pilot indicated that he had "unloaded" the ice and commented that he was able to get over the cloud at Kosciusko without going "to that height". The investigation was unable to determine what the comment "to that height" meant.

The aircraft was observed on radar to be flying a steady north westerly ground track, at a constant altitude of 7,600 ft. The groundspeed stabilised at approximately 145 knots before radar contact with the aircraft was lost at 1243. The controller informed the pilot that radar contact with his aircraft had been lost and nominated a time for the pilot to make an operations normal report.

At 1248 the pilot reported that he was tracking direct to Corryong and had commenced a climb to 10,000 ft. The pilot confirmed that he was tracking north of his original track and again stated that the ice had been "unloaded". He also indicated that the cloud conditions looked much better about 5 or 10 miles north of his planned track.

An unidentified person made several incomplete transmissions, which appeared to be inter-cabin type conversation, on the area VHF frequency. The background noise from these transmissions very closely matched the background noise contained in other reports made by the pilot. At 1252 the person was heard to say, "... you have a standing wave? Well, it's ...".

The aircraft reappeared on the controller's radar display at 1253 flying a south-westerly track, climbing through a transponder-indicated altitude of 8,400 ft with a ground speed of approximately 45 knots. At 1254, as the aircraft climbed through 8,800 ft, the climb performance appeared to reduce significantly. The transponder return stabilised at an altitude of 9,000 ft, although the ground speed did not increase as would normally be expected if the aircraft had levelled out at this altitude. The aircraft was then observed to take up a more westerly track and appeared to be tracking direct for Corryong.

The aircraft disappeared from the controller's radar display at 1257. The last return received from the transponder indicated an altitude of 8,800 ft with a radar-derived ground speed of 47 knots. During the last 20 seconds of recorded data, the transponder indicated a descent of approximately 200 ft, without any significant increase in groundspeed.

Prior to disappearing from radar the aircraft was flying directly towards Mt Jagungal (6,760 ft AMSL) and was operating downwind of the mountain. Meteorological conditions were conducive to the formation of mountain waves and this type of activity was evident on meteorological satellite imagery that had been taken a short time before the accident. Mountain waves, also known as standing waves are characterised by "waves" of ascending and descending air in the lee of a mountain range, and can be associated with moderate to severe turbulence. These waves can extend for significant distances downwind of the range and can pose a serious hazard to the safety of light aircraft.

Several witnesses had seen or heard the aircraft shortly before the accident. One witness saw the aircraft fly overhead, making slow progress towards Mount Jagungal. The engine sounded as if it was operating normally and could still be heard even after visual contact with the aircraft was lost. The witnesses described a low layer of broken cloud close to the ground, with the aircraft apparently flying in clear air above this cloud. Several persons on the ground reported that the aircraft noise increased in pitch, as if in a dive, shortly before the sound of an impact. This account of engine operation to the point of impact indicates that there was no significant reduction in engine power during the final stages of the flight.

The following morning the aircraft wreckage was located at a position that was consistent with the last recorded radar data. It had impacted the ground at high speed, in a near vertical attitude, and in an apparent left turn. Impact forces had destroyed the aircraft, and all six persons on board sustained fatal injuries. The accident site was located 3.4 NM directly east of Mt Jagungal, approximately 5,700 ft above mean sea level.

The impact crater contained the engine and the forward section of the fuselage. The remainder of the wreckage was located a short distance away. Examination of the wreckage did not reveal any defect that could have affected the operation of the aircraft prior to impact.

The pilot held a valid single-engine command instrument rating. He had satisfactorily completed the requirements for the renewal of his rating on 11 April 1997. The pilot had logged a total of 2904.4 hours aeronautical experience, of which approximately 580 hours had been flown in Cessna 210 type aircraft. He had regularly operated his aircraft as pilot in command during the previous 12 months and had frequently flown between Albury and Merimbula under instrument flight rules. The passenger who was believed to have been in the co-pilot's seat held a private pilot licence, which was valid for flight under the visual flight rules.

Colleagues of the pilot reported that he was familiar with the use of the systems on-board the aircraft and would normally use the autopilot during cruise. They stated that his usual habit was to hand fly the aircraft during climb/descent and when operating in turbulent conditions.

The pilot had completed a Class 1 flight crew medical examination on 18 November 1997, which had included a requirement for completion of a stress electrocardiogram (ECG). Although this testing did not return an abnormal result, post-mortem examination of the pilot did reveal that he was suffering severe coronary artery disease. The examining pathologist commented that the stress associated with operating the aircraft in difficult weather conditions could have precipitated a sudden deterioration in his cardiac condition, possibly resulting in a sudden medical incapacitation.

Prior to departing from Albury on the outbound leg of the flight, the aircraft had been fuelled with 200 litres of avgas. It was not possible to determine how much fuel was on board the aircraft prior to the commencement of the fuelling operation. Based on a minimum fuel quantity of 200 litres for departure from Albury, at least 70 litres of fuel is estimated to have be on board the aircraft at the time of the accident.

The aircraft departed Merimbula with sufficient fuel to complete the flight to Albury, with the recommended IFR reserves intact. As it has not been established that the pilot had obtained an aerodrome forecast for his destination, the extent to which he may have made provision for holding fuel or flight to a suitable alternate aerodrome was not determined.

The seating position of the passengers could not be positively determined due to the extent of the destruction of the cabin. Estimated pilot and passenger weights and their assumed seating positions were used to calculate the aircraft operating weight and centre of gravity position. The passenger-seating configuration to provide the optimum centre of gravity position was used in the investigation estimation. Based on these assumptions, at the time of the accident the aircraft was operating below its maximum take-off weight, with the centre of gravity in the vicinity of the published rear limit.

The pilot had regularly operated the aircraft when similarly loaded and would have been familiar with its handling characteristics. The published stalling speed (wings-level) for the aircraft at the estimated load configuration was approximately 64 knots indicated air speed (IAS). The published best rate of climb speed was 92 knots IAS.

Occurrence summary

Investigation number	199801415
Occurrence date	26/04/1998
Location	16 km W Eucumbene
State	New South Wales
Report release date	24/09/1999
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	210
Registration	VH-IOR
Serial number	21064996
Sector	Piston
Operation type	Private
Departure point	Merimbula, NSW
Destination	Albury, NSW
Damage	Destroyed

Glasflugel Gmbh Co Kg, Club Libelle, VH-GJE, Woodbury, Tasmania

Summary

The pilot had undertaken two dual check flights in a training glider on the day of the accident. Both check flights were carried out by a glider pilot who was neither rated nor authorised to conduct them. The duty instructor, who was appropriately rated, was available at the field but did not take part in the checking.

The pilot then flew a Club Libelle single seat glider on the accident flight. Witnesses reported that soon after becoming airborne from a winch launch, the glider was observed to adopt a steep nose high attitude. It then rolled to the left and descended rapidly before impacting the ground where it came to rest inverted. The glider was destroyed in the impact and the 73 year old pilot received fatal injuries.

An examination of the wreckage did not detect any defects which may have contributed to the accident and a post-mortem examination found no pre-existing medical condition which may have resulted in pilot incapacitation.

The investigation determined that the pilot had limited recent flying experience and this was his first flight in this type of glider. The Gliding Federation of Australia (GFA) reported that this glider type has been known to have the seat slide back during the take-off acceleration if it is not correctly locked. As the pilot was of small stature he would have had difficulty controlling the glider if this had occurred and could account for the steep nose high attitude witnessed as the aircraft became airborne. The extensive damage to the glider precluded any determination of the seat position prior to impact.

The factors contributing to this accident were not positively identified. However, the GFA have subsequently taken steps to ensure that the assessment and checking of pilots is carried out in accordance with the requirements of the GFA operations manual.

Occurrence summary

Investigation number	199800770
Occurrence date	28/02/1998
Location	Woodbury, (ALA)
State	Tasmania
Report release date	02/09/1998
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	Glasflugel
Model	205
Registration	VH-GJE
Serial number	Club Libelle
Operation type	Gliding
Departure point	Woodbury, Tas
Destination	Woodbury, Tas
Damage	Destroyed

Amateur Built Lancair 320, VH-LPJ

Safety Action

Local safety action

During the investigation of this occurrence, several Lancair and amateur-built aircraft of other types were found with similar non-compliant engine oil hose fittings. The deficiencies found with the engine installations and documented aerodynamic stalling speeds were referred to CASA. In October 1998, CASA issued AD/LYC/86 Amdt 2, to highlight that any replacement of the steel oil line must comply with the Technical Service Order specifying high heat tolerance (Type D) hoses.

Summary

The pilot of the Lancair 320 aircraft planned to fly, with a passenger, from Archerfield to Rockhampton and return. The aircraft was refuelled at Rockhampton and after an hour's stopover, they departed for Archerfield, on climb to the planned cruise altitude of 5,500 ft above mean sea level. The aircraft left controlled airspace at 1403 Eastern Standard Time. At 1428 Brisbane Flight Service received a Mayday transmission from the aircraft. The pilot indicated that the engine had lost all oil pressure, and that she intended to land on a road. This was the last recorded transmission from the aircraft. The crews of searching aircraft did not hear any transmissions from the missing aircraft's emergency locator transmitter (ELT). The crew of a search aircraft sighted the wreckage at 1815.

The pilot held a commercial pilot licence, and a medical certificate limited to private operations. She had been taught to fly the aircraft type in July 1994, and up to December 1997 had gained 104 hours experience on type. The pilot met the 90-day recency requirement specified in the Civil Aviation Regulations pertaining to the carriage of passengers. However, with the exception of a 30-minute flight on 13 December 1997, the only flying experience gained by the pilot in the last 90-days was the 3 hours flown on the day of the accident. The passenger held a private pilot licence but was not experienced on the aircraft type.

The wreckage was located about 380 m south of a dirt road aligned 080/260 degrees M. The road was new and unusually wide due to the recently constructed clearway through the coastal forest. it had a natural surface and was suitable for an emergency landing. The surface wind at the time of the accident was an easterly at about 15 kts.

Examination of the accident site revealed that the aircraft struck the ground at an angle of 45-50 degrees nose-down and banked approximately 90 degrees left. The left wingtip struck the ground first. The aircraft then cartwheeled, traversed a windrow of felled trees, and came to rest inverted, aligned approximately 345 degrees M, 22 m from the initial impact point. The engine, firewall and instrument panel had separated from the fuselage in one piece. The empennage had separated in a whiplash action and had come to rest 8 m beyond the fuselage, also aligned approximately 345 degrees M. The landing gear was locked in the extended position and the wing flaps were retracted. A significant quantity of oil had escaped from the engine during flight, as evidenced by oil along the lower fuselage. A search of the area where the aircraft was parked at Rockhampton found a small pool of fresh oil consistent with engine oil dripping from the engine cowling during the stopover. It could not be established if oil had been added to the engine at Rockhampton.

The ELT was mounted in the rear of the fuselage but was disconnected from its aerial due to impact forces. The unit was turned off 42 hours after the accident. Later specialist examination found that the near-new batteries were almost depleted, indicating that the unit had been operating but not radiating effectively without its aerial.

The engine was removed to an engineering workshop and dismantled under the supervision of BASI investigators. Approximately 1 L of oil was recovered from the engine and there was no sign of seizure damage to any engine component. Specialist engineering opinion was that the engine was serviceable before impact. Destruction dynamics of the wooden-bladed, variable-pitch propeller assembly indicated that the engine was producing power at impact. During removal of the engine ancillary components, a high-pressure oil hose was found to be holed. The braided steel, rubber-lined hose had been resting on the Number 1 cylinder exhaust pipe and had worn through due to vibration and heat.

The oil hose had been fitted to replace the engine manufacturer's stainless-steel line between the propeller hub and the propeller governor at the rear of the engine crankcase. Replacement of the stainless-steel line with a braided steel hose was authorised by Civil Aviation Safety Authority (CASA) Airworthiness Directive (AD) AD/LYC/86 Amdt. 1 issued on 12 July 1990. The AD referred to Textron Lycoming Service Instruction 1435, which specified a Type D, teflon hose with steel braiding/fire-sleeving, and instructions on clamping/routing. The item fitted to the aircraft was a Type A, steel-braided, rubber hose of lower specifications than the Type D hose and was clamped/routed incorrectly. The aircraft was amateur-built by its previous owner. The hose had been installed before the aircraft's initial airworthiness inspection prior to being placed on the Australian Aircraft Register.

Forty flight-hours before the accident, the engine's cylinders had been removed/refitted during unscheduled maintenance. The aircraft had also undergone a periodic inspection at the same maintenance organisation 19.4 flight hours before the accident.

Although the engine did not show any signs of seizure and some oil remained, the length of time that the engine may have continued to operate could not be determined. Bundaberg aerodrome, 72 km from the accident site, was the nearest suitable aerodrome. Considering the loss of oil pressure, the pilot's decision to carry out a precautionary landing on a road in an area devoid of other suitable landing sites was appropriate. The circumstances of the approach could not be determined. Although the wing flaps had not been configured for landing, the disposition of the wreckage was consistent with a right-base position for landing into wind. The attitude of the aircraft at impact was consistent with a loss of control at a height from which recovery was not possible.

Comparison of limitation data contained in the aircraft flight manual and the flight test results contained in the aircraft files held by CASA revealed a discrepancy in the documented aerodynamic stalling speeds. The stall speeds specified in the aircraft flight manual were lower by 2 kt when compared with the relevant flight test power-off stalling speeds.

Although not implicated in the accident sequence, two other discrepancies were found which involved the fitment of an automotive engine oil filter to the engine, and a right-angle drive adaptor for the rear mounted propeller governor. Neither was covered under an Australian Engineering Order or Supplemental Type Certificate for the Textron Lycoming engine.

During the course of the investigation, it was reported that maintenance by unqualified personnel had been performed on the propeller system following the last periodic inspection. This could not be substantiated.

Occurrence summary

Investigation number	199800740
Occurrence date	12/03/1998
Location	72 km NW Bundaberg, Aero.
State	Queensland
Report release date	25/03/1999
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	Amateur Built Aircraft
Model	Lancair 320
Registration	VH-LPJ
Serial number	Q063
Sector	Piston
Operation type	Private
Departure point	Rockhampton, QLD
Destination	Archerfield, QLD
Damage	Destroyed

Air Tractor AT-802, VH-ODL

Significant Factors

The aircraft speed rapidly reduced during an unusually steep climb.
The flaps extended beyond 10 degrees during the climb.
Control of the aircraft was lost at a height from which recovery was not possible.

Analysis

Video evidence indicated that the approach to the water drop was normal, although the airspeed approaching the target area was about 10 kts higher than the maximum recommended in the AFM for load release. The aircraft nose would have suddenly pitched-up during the release of the load and there was no evidence of any significant elevator input to counteract the change in nose attitude.

Although the pilot had only logged 7.6 hours operating aircraft equipped with the Fire Retardant Dispersal System, he was sufficiently experienced on the aircraft type to appreciate the magnitude of pitching moment likely to be encountered. Insufficient forward elevator had been applied during the release of the load to counter the tendency of the aircraft nose to pitch upwards.

There was no evidence to indicate that a mechanical defect or medical incapacitation had contributed to the lack of elevator input during the load release and subsequent climb. It was possible that the pilot had intended to climb the aircraft steeply after releasing the load in an attempt to increase the visual impact of the display, which was consistent with comments attributed to the pilot about his stated intention to put on a good display. The observed yawing and rolling to the left during the climb may have been an attempt by the pilot to turn the aircraft for another pass of the crowd.

The extension of flap during the climb would have created a significant amount of additional drag. Consequently, for the aircraft to reach a height of 450 ft with the amount of flap being applied, it was likely that the engine was operating at a high power setting and the propeller producing a significant amount of thrust and resultant torque.

It was not possible to determine whether the extension of flap beyond 10 degrees during the climb was intentional. The extension of the flaps probably reduced the likelihood of the manoeuvre being safely completed. Although the extension of flap during the climb may have caused the aircraft nose to pitch-up further than the pilot had originally anticipated, there was no evidence that the pilot had made an elevator input to reduce the steepness of the climb.

The ailerons would have become less effective as the airspeed of the aircraft reduced during the climb. The low airspeed combined with the apparent turning manoeuvre, reduced aileron effectiveness and high torque being produced by the propeller probably contributed to the aircraft's roll inverted and entry to the incipient inverted spin. Once the aircraft had entered the spin, it was unlikely that there was sufficient height available for the pilot to effect a recovery.

Summary

The pilot of the Air Tractor 802A (AT-802A) was scheduled to demonstrate the fire-fighting capabilities of the aircraft at the Mount Gambier airshow. After becoming airborne the pilot positioned the aircraft for the first pass of the crowd. This pass was made at a height of approximately 100 ft in a north easterly direction and overhead the runway that was being used as the display axis for the airshow.

The pilot then confirmed by radio to the airshow coordinator that he was starting his "drop run". The aircraft was observed to fly in a gentle descent towards the designated target area, and at a height of about 40 ft the load release commenced at, or close to, the maximum rate. During the load release the nose of the aircraft pitched up and the aircraft entered a climb. On completion of the load release the aircraft nose continued to pitch up and the climb angle increased.

The aircraft climbed straight ahead for a short distance before commencing to yaw and roll to the left. The bank angle increased to a maximum of about 90 degrees while the nose attitude dropped to almost the horizontal. At a height of about 450 ft and while at very low airspeed, the aircraft rolled inverted and entered the incipient stages of an inverted spin. Recovery to controlled flight was not achieved and the aircraft impacted the ground inverted, in a wings level attitude at a nose-down angle of approximately 45 degrees.

The aircraft caught fire immediately after it struck the ground. The fire was fed by aviation turbine fuel from the ruptured fuel tanks and was quickly brought under control by local firefighting services which had been on stand-by at the aerodrome. The pilot sustained fatal injuries. Impact forces and the ensuing fire destroyed the aircraft.

Wreckage and impact information

Fire had affected the forward fuselage, consumed most of the right wing and the inboard portion of the left wing. The left wing flap was at an almost fully extended position and the right wing flap was destroyed by fire. Examination of the wreckage did not reveal any mechanical defect that may have contributed to the loss of control.

An examination of the aircraft's propeller revealed that the blades remaining within the propeller hub were in an approximate coarse pitch setting. One of the blades had dislodged from the hub on impact with the ground and an adjacent blade had fractured in close proximity to the hub.

The engine and propeller were dispatched overseas to the engine manufacturer for further examination. Examination of the engine revealed no evidence of pre-impact distress or operational dysfunction. The engine damage was consistent with it producing high power at impact.

The engine manufacturer subsequently reported that they could find no record of receiving the propeller. Despite additional inquiries, the propeller could not be located and consequently it was not possible to conduct a detailed examination of this component. Therefore, it was not possible to establish if the propeller blade angle observed at the accident site was due to impact forces, a result of a malfunction, or because of a control input by the pilot.

Pilot information

The pilot in command was appropriately licensed and qualified to undertake the flight. He held a valid Commercial Pilot Licence and Grade 1 Agricultural Rating and had accumulated a total of approximately 11,354 hours aeronautical experience, including 182.5 hours logged in AT-802A type aircraft. The pilot was experienced in airborne fire-fighting operations and was professionally employed in that capacity.

The Civil Aviation Safety Authority (CASA) had issued the pilot with a class one medical certificate. The CASA Acting Director of Aviation Medicine reviewed the pilot's medical history file together with the pathologist's report of the post-mortem examination. He reported that it was unlikely there was a direct medical factor involved in the apparent loss of aircraft control.

The pilot had previously completed demonstration flights of the AT-802 aircraft. One of the owners of the aircraft reported that he had spoken to the pilot about flying at the airshow a few days before the accident. They discussed some aspects of this type of event, in particular the potential for a pilot to impulsively initiate an impromptu routine. The aircraft owner reported that the pilot said that this was not going to be a problem and appeared quite subdued about his participation in the event.

A number of people reported that they had spoken to the pilot on the day of the accident. He had given the impression that he intended putting on a "good display" and that he thought a high-speed load release would look spectacular. The pilot reportedly also commented about the high standard of some of the other display routines and that he would "pull something out of the box" to impress the crowd. Aircraft information

The AT-802A had a five-blade constant-speed propeller that was powered by a PT-6 turbine engine. The accident aircraft was specifically equipped to conduct airborne fire-fighting operations and was fitted with a computer controlled Fire Retardant Dispersal System. The system had the capacity to deliver high volumes of water through a pair of hydraulically operated, computer controlled doors at the base of the hopper at rates well in excess of conventional delivery systems. The pilot used a control panel in the cockpit to select the ground coverage rate and the quantity of hopper contents to be delivered. The hopper capacity was 3,104 litres.

The pilot had logged approximately 7.6 hours flying aircraft that were equipped with this type of dispersal system. The investigation could not determine the number of times the pilot had used the system or the types of delivery he had made.

The AT-802A wing was equipped with fowler type flaps, which extended to a maximum setting of 30 degrees. The approved Aircraft Flight Manual (AFM) recommended that during fire control operations the flaps be set to 10 degrees for approach and load release and that flaps may be used as an aid in turning when extended to a maximum of 8 degrees.

Extending the flaps beyond 10 degrees resulted in a significant amount of additional drag and flap extensions greater than 10 degrees was normally used only for landing. The flaps could be selected by the pilot to any position between 0 and 30 degrees using a switch, mounted just below the throttle quadrant, or by a toggle switch mounted on the control stick. Experienced AT-802A pilots reported that it was possible to inadvertently extend the flaps by unintentionally activating the switch mounted on the control stick. Extending the wing flaps resulted in a conventional nose-up pitching moment.

The AT-802A type aircraft was certified by the US Federal Aviation Administration as an aircraft for "special purpose operations". Flight-testing during the certification process assessed the aircraft as being compliant with the Federal Aviation Regulations (FAR) which required an aircraft to demonstrate satisfactory aerodynamic stalling characteristics. Because low altitude agricultural type operations were considered to significantly reduce the probability of recovery from a spin, the aircraft's compliance with the FAR relating to satisfactory spin recovery characteristics was not required to be assessed.

The AFM for the AT-802A prohibited acrobatic flight manoeuvres, including spins. The manual also noted that during fire control operations the load release should be conducted at an airspeed between 109 and 113 kts and recommended that 10 degrees of flap be used to approach the target area and for the load release. In addition, the AFM advised pilots to "be aware that during the load release there will be a sudden pitch-up of the nose of the aircraft" and to "begin forward motion on the control stick as soon as the drop button has been activated".

Pilots experienced on the AT-802A reported that the intensity of the pitching moment depended on the aircraft's speed and the rate at which the hopper was emptied. The most significant pitching moment occurred when the full hopper contents were released at the maximum rate, at an airspeed exceeding 125 kts. It was also reported that a pilot experienced on the AT-802A should be able to anticipate the intensity of the nose pitch and accordingly, could be expected to safely control the climb profile of the aircraft.

Weather conditions

The weather conditions at the time of the accident were generally fine with a light to moderate south easterly wind. The temperature was about 23 degrees C and there was scattered cloud at 3,000 ft. The prevailing weather conditions were not considered to have been a factor in the accident.

Video & photographic information

Analysis of video and photographic evidence revealed that the aircraft approached the designated target area with about 10 degrees of flap extended and at an airspeed of about 125 kts. The elevator remained approximately in a neutral position during the release of the load and the aircraft nose commenced to pitch up, reaching an angle of approximately 45 degrees on completion of the delivery. The wing flaps extended to at least 25 degrees during the first part of the climb with the elevator remaining close to a neutral position. The climb angle then progressively steepened to about 70 degrees. Pilots experienced on the AT-802A assessed the initial delivery of water and foam to be normal, however the subsequent aircraft climb profile was abnormally steep.

After the aircraft had rolled inverted, it adopted an almost flat attitude, consistent with the incipient stages of an inverted spin. Movement of the elevator control was evident during the initial stages of the spin, however due to the resolution of the video recordings, it was not possible to conclusively assess any other movements of the control surfaces.

Occurrence summary

Investigation number	199800640
Occurrence date	01/03/1998
Location	Mt Gambier, Aero.
State	South Australia
Report release date	04/07/2000
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	Air Tractor Inc
Model	AT802
Registration	VH-ODL
Serial number	802A-0056
Sector	Turboprop
Operation type	Private
Departure point	Mt Gambier, SA
Destination	Mt Gambier, SA
Damage	Destroyed

Cessna 210N, VH-SJP

Significant Factors

The pilot had limited recent and total night flying experience.
The flight arrived after dark, and later than intended.
The night was dark, with no visual horizon.
The pilot did not retain control of the aircraft.

Analysis

The available evidence indicates that the aircraft arrived in the area of the mine later than planned, but not having encountered any difficulties. When flying over the mine the pilot was probably flying with reference to the ground lighting and then the runway lighting. By flying to the right of the runway lights he would have been in a good position to examine the windsock in order to decide which direction to make a landing and to determine the wind velocity.

Having made this assessment, it is likely that he then commenced a right turn to track from the runway to join on the downwind leg for a landing toward the south-east. The impact location and direction are consistent with such a manoeuvre. As the pilot commenced the turn, he would have lost visual reference with the runway and other lights. This would have required him to fly the aircraft solely with reference to the cockpit instruments. The attitude of the aircraft at impact indicated that he did not maintain control of the aircraft sufficiently to prevent it entering a steep descending turn.

Summary

The pilot submitted a flight plan indicating a planned departure from Cobar at 1500 ESuT (1400 EST). A refuelling stop was to be conducted at Windorah. The planned arrival time at Osborne Mine was 1830 EST. Last light in the area was 1931.

The aircraft left Cobar at about 1455 EST. (The reason for the late departure was not established.) The planned flight time to Windorah was 2 hours 40 minutes. The aircraft was on the ground at Windorah for about 1 hour 30 minutes, apparently because the passengers walked to the township. Refuelling was completed at Windorah at about 1845. The planned flight time from Windorah to Osborne Mine was 1 hour 30 minutes. The pilot contacted the mine by radio and reported that he would be arriving at 2030. The runway lights were then activated by the mine staff.

A witness at the mine saw the aircraft, with navigation lights operating, fly overhead at an estimated height of 300 ft above ground level, considerably lower than the normal aircraft altitude. The aircraft was visible in the glow of the lights at the mine. A short time later, the witness was in a position to see the runway lights, and noted that the aircraft was to the north of the runway. He then lost sight of the aircraft as he drove the remaining distance to the strip. Later, he reported to the mine's communication centre that the aircraft had not landed. A formal search was commenced at 2100 when the pilot failed to cancel his search and rescue watch. A satellite which monitors transmissions from emergency locator beacons detected a beacon signal at 2132, when it passed over the accident area. The aircraft wreckage was subsequently located about 400 metres north of the airstrip.

Wreckage examination

Examination of the wreckage indicated that the aircraft struck the ground at a high rate of descent, and banked about 50 degrees right. Aircraft speed at impact was estimated at about 100 kts, and the engine was developing moderate power. No fault was found in any aircraft system which might have contributed to the accident. The impact was not survivable.

Pilot experience

The pilot was the holder of a private pilot's licence and a current medical certificate. He held a Night Visual Flight Rules rating and had accrued 30.4 hours of night flying experience. To act as pilot in command of an aircraft under these rules it was necessary for the pilot to satisfy a number of recent experience requirements. These included one hour flight time at night in the previous 12 months; one take-off and landing at night in the previous six months to fly without passengers; and three take-offs and three landings at night within the previous 90 days in order to carry passengers in the aircraft. According to the pilot's logbook he had not met any of these criteria. His most recent night flying had been conducted in late July 1997.

Flying conditions at Osborne

Some high cloud was present in the mine area. Visibility was good, but the night was dark with no moon and no visual horizon. The wind was blowing from the north-east at right angles to the runway and about 10 to 15 kts in strength.

A parking area and lit windsock were located on the southern side of the airstrip near its south eastern end. The runway lighting system contained a series of lights which pilots could use as a glide slope indicator when landing towards the south-east. Since the pilot had never previously landed at the airstrip during darkness it is not known whether he was aware of this feature.

Occurrence summary

Investigation number	199800604
Occurrence date	26/02/1998
Location	Osborne Mine
State	Queensland
Report release date	07/05/1999
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	210
Registration	VH-SJP
Serial number	21063473
Sector	Piston
Operation type	Business
Departure point	Windorah, QLD
Destination	Osborne Mine, QLD
Damage	Destroyed

Subscribe to Collision with terrain