[Peetwo]

Busy week in the Hooded Canary avery?? -   

First with an update to the tragic C210 crash near Mount Isa on May 26 -   

Investigation update: 7 June 2019
The information contained in this investigation update is derived from the initial investigation of the occurrence. Readers are cautioned that there is the possibility that new evidence may become available that alters the circumstances as depicted in the report.

What happened

At 1407 Eastern Standard Time[1] on 26 May 2019, a Cessna Aircraft Company 210M, registered VH-SUX and operated by Thomson Aviation, departed Mount Isa Airport for an aerial geological survey flight. There were two pilots on board, one operating the aircraft and the other observing the flight to familiarise himself with the survey area. The survey was to be conducted at a target height of about 200 ft above ground level along parallel east and west lines, spaced about 90 m apart.

The evidence indicated that about 1 hour and 40 minutes into the flight, as the aircraft tracked west along the sixth survey line, the right wing separated, resulting in a rapid loss of control and subsequent collision with terrain. The pilots were fatally injured and the aircraft was destroyed.

Wreckage and site information

The accident site was located about 25 km north-east of Mount Isa Airport in flat, arid scrub land (Figure 1). The wreckage trail was on an approximate east to west heading, in line with the expected survey flight path. The right wing was the first major component in the wreckage trail and was located about 130 m from the main wreckage. The aircraft impacted terrain about 90 m from the right wing, coming to rest a further 40 m away. All major aircraft components were accounted for at the site.

Figure 1: Accident site overview looking east

Source: ATSB

On-site examination of the wreckage indicated the right wing and part of the carry-through spar[2] had separated from the aircraft (Figure 2). Preliminary examination of the spar identified that it had fractured through an area of pre-existing fatigue cracking. The fracture was located inboard of the wing attachment lugs.

The carry-through structure was removed for detailed examination.

Figure 2: Right wing viewed from inboard end showing section of carry-through structure

Source: ATSB

Initial findings

Technical examination of the carry-through structure was conducted at the ATSB’s Canberra facilities. This examination confirmed that the fatigue cracking reduced the structural integrity of the carry‑through to the point where operational loads produced an overstress fracture of the remaining material. The fracture location was approximately 290 mm inboard of the right wing fuselage attachment lugs and coincident with a change in section thickness of the lower flange (Figures 3, 4 and 5). Characteristic features identified across the fracture surfaces confirmed that the fatigue cracking had initiated from the underside surface, growing across the lower flange and penetrating vertically into the structure.

Figure 3: The approximate location of fracture

Source: Cessna, modified by the ATSB

Figure 4: Carry-through structure, as received at the ATSB’s facilities

Source: ATSB

Figure 5: Close view of the outboard portion of the fracture surface (fatigue cracking has initiated on the underside surface)


Source: ATSB

Aircraft details

The Cessna Aircraft Company (Cessna) 210M is a high cantilever wing, piston-engine aircraft with a three-blade variable-pitch propeller and retractable tricycle landing gear (Figure 6). The aircraft is normally fitted with six seats. The accident aircraft (serial number 21061042) was manufactured in the United States in 1976 where it operated until 2013. It was imported to Australia and registered as VH-SUX in June 2013. At that time, the aircraft was modified for geological survey work, which included the removal of the passenger seats and the installation of specialised equipment.

Figure 6: VH-SUX


Source: Operator

The aircraft also had Supplemental Type Certificates for the installation of integral wing tip fuel tanks and a non-standard engine and propeller installation.

VH-SUX accumulated about 6,000 flight hours in the 6 years it was on the Australian register. It was operated exclusively as a geological survey aircraft during that time. The aircraft had 12,174 flight hours total time in service at the time of the accident.

Operation

The flight was one of a number of flights undertaken for the purpose of a geological survey to the north and north-east of Mount Isa.

The survey was conducted in a grid pattern, with closely spaced east and west lines along with more widely spaced north and south lines flown for data verification purposes. The flight profile closely followed the topography of the survey area at a speed of about 140-150 kt with procedure turns flown at each end of a survey line.

Each flight typically lasted for about 5 hours with multiple flights required to complete each survey. Two flights were normally flown each day in accordance with allowable environmental and daylight conditions, each flight on a given day being operated by a different pilot.

The aircraft typically departed with full fuel, resulting in it operating at close to the maximum allowable take-off weight.

Safety action

On 31 May 2019, the ATSB notified the Civil Aviation Safety Authority, the US National Transportation Safety Board, the aircraft manufacturer and operator of the initial finding of fatigue cracking within the wing spar carry-through structure.

The ATSB is working closely with those organisations to ensure the continued safe operation of the aircraft type.

Further investigation

The investigation is continuing and will include:

• a metallurgical examination of the wing carry-through structure and associated parts
  
  
• further examination and assessment of the aircraft wreckage
  
  
• examination of the maintenance procedures and inspections associated with the wing spar carry-through structure
  
  
• factors that may have contributed to the development of fatigue cracking
  
  
• the operational history of the aircraft from 1976 until 2013.
  

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& from LMH:






Fatigue Failure caused Wing Separation in C210 Crash
7 June 2019
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The Australian Transport Safety Bureau (ATSB) today said that fatigue cracking in the wing carry-through spa was responsible for in-flight wing separation on a Cessna 210 near Mount Isa.

VH-SUX was on a geological survey flight with two people on board when it crashed near Mount Isa on 26 May this year. Both people were killed in the crash.
"Evidence at the accident site indicated that the aircraft’s right wing had separated while in flight, resulting in a rapid loss of control and subsequent collision with terrain," the ATSB said.

"Subsequent technical examination confirmed the aircraft’s wing spar had fractured due to fatigue cracking, which reduced the spar’s structural integrity to the point where operational loads produced an overstress fracture."

ATSB Executive Director Nat Nagy said that the ATSB had notified the relevant National Aviation Authorities.

“The ATSB has notified the Civil Aviation Safety Authority, the US National Transportation Safety Board, the aircraft manufacturer and operator of the initial finding of fatigue cracking with the wing spar carry-through structure,” Nagy said.

"The ATSB is working closely with those parties to ensure the continued safe operation of the the aircraft type."

Fatigue cracking is most often related to the age of a metal component and happens when a small crack grows to the point that the cross-section of a component is reduced to the point where it can't carry the load imposed.

The fear of fatigue in older aircraft was one of the driving factors behind the controversial Cessna Supplemental Inspection Documents (SIDs) programs that were to have been completed for charter and aerial work by the end of July 2016. The SIDs required non-destructive testing and inspections for both primary and secondary aircraft structural components.

The ATSB has moved to differentiate this accident from two other fatal accidents involving C210s in WA and NT. Both of those accidents were attributed to over-stressing of the wings in flight.

Read more at http://www.australianflying.com.au/lates...BVye0hw.99

 
And on the Yak tragedy near South Stradboke island, which appear to have some disturbing parallels to the Barry Hempel and Andrew Lovell accident   :

The ATSB is investigating a collision with water involving a Yakovlev Yak-52, registered VH-PAE, near South Stradbroke Island, Queensland, on 5 June 2019.

The pilot and passenger had departed Southport Airport on a 30-minute scenic flight of the Gold Coast area. The aircraft did not return at the scheduled time and was reported missing. A search was commenced, with aircraft parts subsequently found on South Stradbroke Island. As at midday 6 June the search was continuing.

As part of the investigation the ATSB will liaise with the Queensland Police Service and interview involved parties and witnesses. The ATSB will also examine the recovered aircraft wreckage and collect other relevant evidence and information.

Any witnesses are asked to call the ATSB on 1800 020 616 or complete the ATSB’s online form www.atsb.gov.au/witness

A report will be released at the conclusion of the investigation. However, should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate action can be taken.

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Pilot Marcel van Hattem confirmed dead as wreckage of missing plane located
By Jennifer Huxley and Kate McKenna
Updated yesterday at 10:56am




PHOTO: Marcel van Hattem and his Yak 52 at Southport Airport. (Facebook: Marcel van Hattem)

RELATED STORY: Debris spotted in search for Soviet-era plane missing off Gold Coast

Emergency authorities have found the body of pilot Marcel van Hattem in the wreckage of his light plane, discovered in waters off South Stradbroke Island on the Gold Coast on Thursday afternoon.

Key points:

• Pilot Marcel van Hattem had taken Trista Applebee on a joy flight for her birthday when they went missing
  
• Police divers found Mr van Hattem's body and are still searching for Ms Applebee
  
• Southport Flying Club president Neil Aitkenhead said Mr van Hattem was a very experienced pilot
  

Police said they were still looking for his 31-year-old female passenger Trista Applebee and the remainder of the plane's wreckage.

The Yak 52 Soviet-era plane was reported missing on the Gold Coast on Wednesday.

Ms Applebee had been on a joy flight for her birthday at the time, police said.

Ms Applebee and Mr van Hattem, 52, a Dutch-national, were both Gold Coast residents.

Mr van Hattem took off from the Southport Flying Club around 10am on Wednesday on a half-hour scenic flight over South Stradbroke Island, but never returned.

"It's actually her birthday today," Officer in Charge of the Gold Coast Water Police, Senior Sergeant Jay Notaro said on Thursday morning.

"The pilot was known to her and was providing that flight for her as part of her birthday celebrations."

He said authorities were having difficulties reaching the family of the pilot.

It is the same model plane that crashed in a similar location in 2008, claiming two lives.

Mr van Hattem's friend Deborah Toussaint told the ABC he had two teenage sons.

VIDEO: Deborah Toussaint flew with Marcel van Hattem just a few weeks ago and even took the controls of the plane. (Supplied)(ABC News)



"[He] took me for a joy ride in his plane only weeks ago … he was such a generous and beautiful man … he knew what he was doing and he was an excellent pilot," she said.


"I feel for his boys who are not here in Australia."


The search is continuing with the assistance of Polair and the Westpac Lifesaver Rescue Helicopter, jet skis, all-terrain vehicles, police vessels and volunteer marine rescue groups.


Senior Sergeant Notaro said police were also using underwater sonar equipment in the search for the plane.

"A lot of that debris has been within the waves and the conditions are quite tricky and that's what's hampering our efforts," he said.

"There's always hope and we're acting upon that hope right now, trying to get some answers for both the families involved.

"Anyone who locates any debris is asked not to touch it and called police link immediately.

"I'm calling upon any witnesses who may have seen this plane between the hours of 10.00am and 11.00am yesterday in the proximity of the coastline of South Stradbroke Island."


PHOTO: Police divers in the water assisting in the search. (ABC News)



Pilot regular at airstrip and 'very experienced'


Southport Flying Club president Neil Aitkenhead said Mr van Hattem was a regular at the airstrip and "very experienced".


"It's always bad news to hear and until we know more, there's not a lot we can do," he said.

Mr Aitkenhead said the conditions had been "perfect" for flying and the aircraft was "very reliable, solid and Russian-built".

The Yak 52 is a Soviet-era training aircraft often used for aerobatics and scenic flights.

  
Next a rare (for the ATSB) actual interim report/update, on the anniversary of the crash of VH-EWE -    

Updated: 7 June 2019

The investigation into the collision with terrain involving Cessna 172S, VH-EWE, near Moorabbin Airport, Victoria, on 8 June 2018 is continuing.

The investigation is currently in the examination and analysis phase, which includes the examination of retained aircraft and engine components, maintenance documentation, the pilot’s experience, fuel records, and available electronic data.

During this phase, the available evidence is reviewed and evaluated to determine its relevance, validity, credibility, and relationship to other evidence and to the occurrence. Evidence can be vague, incomplete and or contradictory. This may prompt the collection of more evidence, which in turn needs to be analysed and examined – potentially adding to the length of an investigation.

Once the evidence analysis phase is complete, a final report will be drafted and undergo a rigorous internal review to ensure the report findings adequately and accurately reflect the analysis of available evidence. Final investigation reports also undergo other technical and administrative reviews to ensure they meet national and international standards for transport safety investigations.

Following the completion of the internal review, a draft of the final report will be sent to all directly involved parties for their comment before the report is finalised and published

Currently, the anticipated completion and publication date of the final report is during the fourth quarter of 2019. However, should any safety issues be identified during any phase of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.

And finally an actual final report...   - 

Loss of control and collision with terrain involving Cirrus SR22, VH-PDC, Orange Airport, NSW, on 15 May 2018

What happened

On 15 May 2018, at 1903 Eastern Standard Time, a Cirrus SR22 aircraft, registered VH‑PDC, collided with terrain at Orange Airport, New South Wales. The accident was a night training flight with one pilot (aircraft owner) and one flight instructor on board. The pilot and instructor were seriously injured and the aircraft destroyed.

What the ATSB found

The ATSB found that the pilot, who was conducting his first night training flight, likely became spatially disorientated during a go-around manoeuvre, which resulted in a loss of control at low level and collision with terrain.

The flight instructor did not intervene to take control of the aircraft during the go-around manoeuvre, because she was not aware the pilot had become spatially disorientated and was accustomed to directing the pilot to correct control problems. Inconsistent with Civil Aviation Safety Authority guidance, the instructor, who had previously instructed the pilot for his private instrument rating, did not provide a night flying demonstration before directing the pilot around the circuit.

Safety message

It is important for flight instructors to provide a demonstration when introducing a pilot to a new flight sequence or new flight environment. Time spent demonstrating the key points of a new sequence or environment will usually improve the learning process by ensuring that the development of a new skill is supported and preceded by knowledge and understanding from experience.

The flight instructor reported that for the delivery of future initial night flying training, she would conduct either a separate session of daytime flying training circuits prior to night, or deliver the training as day-into-night circuit training. She also commented that, prior to teaching night flying, flying training organisations should consider conducting refresher training in unusual attitude recoveries, irrespective of a pilot’s level of experience and qualifications.

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Disorientation caused Cirrus Crash: ATSB
6 June 2019
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The Australian Transport Safety Bureau (ATSB) has found that spatial disorientation contributed to the crash of a Cirrus SR22 at Orange last year.
A pilot and instructor were on board VH-PDC conducting night training at Orange in May 2018 when the aircraft crashed during a go-around attempt. The aircraft was destroyed and both the occupants were seriously injured.

The ATSB investigation report released today found that during the go-around the pilot became spatially disoriented, which resulted in a loss of control. According to the report, the instructor was not aware the pilot had become disoriented and so continued to direct the pilot rather than intervene.

During the go-around, the aircraft pitched up in response to power and began to roll to the left. Because the pilot–who had a private instrument rating–lost sight of the runway lights and the night was pitch black, he became disoriented.

"When full power was applied, the aircraft pitched up," the report states. "As the pilot was attempting to transition his scan onto the instruments, the instructor, whose attention was on the attitude indicator, directed him repeatedly to level the wings – 'wings level'.

"The pilot observed the runway lights disappear off to the right and felt the aircraft was in a roll as he was trying to focus his attention on the attitude indicator."

Although the pilot reported trying to correct the aircraft, it struck a fence and came to rest upside down. The time from the decision to go-around to impact was only seven seconds.

The instructor reported that she did not take control in this situation because the side-stick in the SR22 made it difficult to do so, and also because the during the previous night circuit the pilot had responded well to direction. She also said that by the time she understood the pilot was disoriented there was no time left to avoid the crash.

The incident also prompted the ATSB to issue a warning to would-be rescuers about the risk involved with ballistic recovery systems (airframe parachutes). In this instance, the Cirrus Airframe Parachute System (CAPS) rocket fired uncommanded nine minutes after the crash.

"The post-impact deployment of the aircraft’s parachute recovery system highlights an important safety message for emergency personnel and others who attend aviation accidents, to be aware of the potential dangers of an unactivated rocket-deployed parachute systems," the ATSB warned.

"The mishandling or misidentification of these systems could be fatal."

The full investigation report and ballistic recovery system warning can be found on the ATSB website.

Read more at http://www.australianflying.com.au/lates...krC6gkK.99

On the last in case you missed it here is the ATSB spectacular video footage of the CAP rocket firing off from the burning wreckage of the Cirrus...  

 

MTF...P2