Accident Investigations

	RA-Aus Accident Investigations Rev. 4a — page content was last updated July 7, 2007
Operations

Most studies of aircraft accidents reveal not a single cause but a series of interrelated factors, events or actions that — being allowed to progress without appropriate action or intervention — lead to an unplanned termination of the flight operation.

Pilot error is a major factor in 80–90% of all accidents that result in significant aircraft damage; other human error is a major factor in most of the remainder. A study of the factors contributing to fatal general aviation accidents in Australia for the ten years up to 2000 showed that flight planning was a factor in 38% of the accidents, aircraft handling errors in 30%, and fuel starvation or fuel exhaustion in 10%.

Dr Rob Lee, the then Director of the Australian Bureau of Air Safety Investigation, wrote in 1998: "Over 40 years of investigation of General Aviation accidents by BASI and its predecessors clearly shows that while the immediate circumstances of each accident may well be unique, the underlying factors are always drawn from the same disturbingly familiar cluster — pre-flight preparation and planning, decision making, perception, judgement, fuel management and handling skills".

RA-Aus investigates some accidents and incidents with the sole intention of reducing the likelihood of the same accident happening again. The investigation and the subsequent report is not a means to apportion blame. RA-Aus believes it inappropriate to publish all investigation reports in full because they are just a repetition of the same old pilot errors. Pilots would be better served if they devoted time to absorbing the safety-related material contained in the various guides published in this web service.

Some selected reports from our investigations are published in this section of the RA-Aus web service as illustrations of Dr Lee's remarks. Short extracts from other accident or incident reports are included at appropriate points within the text of the various flight theory, flight planning and emergencies modules to support guide material, while similar extracts appear in the monthly journal issued to all RA-Aus members.

If an accident investigation or incident report indicates a possible aircraft defect it will culminate in publication of an airworthiness notice or warning to operators of a particular aircraft, engine or propeller type; all such notices issued since 2000 appear in the airworthiness notices and other advices section on this web site. New notices are also published in the monthly journal.

Bantam B22S — Caloundra, Qld 22 February 2005

Extract: "RA-Aus must continue to educate our pilots of the fatal consequences of turn-back manoeuvres."

The accident report is available in MS Word format only.

Tecnam P92 Echo Super — Denman, NSW 27 June 2004

Extract: "Although the evidence presented is inconclusive with determining a cause for the initial failure of the engine, it cannot be over stressed to flying members the importance of practicing emergency procedures in safe and controlled environments. Practice of simulated emergencies is essential for all pilots in order to facilitate effective emergency skills in real life situations."

The accident report is available in MS Word format only.

Corby Starlet — near Rochester, Vic 4 October 2003

Extract: "While cruising at 3000 feet in the company of two other aircraft the pilot of the Corby Starlet performed a successful barrel roll to the left followed by one to the right which was not executed as cleanly as the first and the pilot transmitted that his engine had failed. The approach speed in the subsequent forced landing was much too fast."

The accident report is available in MS Word format only.

Airborne Edge X — Sunbury, Vic 19 Dec 2002

Extract: "Action for the AUF: To bring to our member's attention the need for careful planning and the necessity of expecting an engine failure at any time."

The accident report is available in html format without images but a Microsoft Word version with photographs is also available.

Drifter – Cunningham's Gap, Qld 22 February 2003

Extract: "RA-Aus must continue to educate pilots on the limitations of their aircraft and the certain fate that awaits them if they enter IMC with no training and no instruments."

The accident report is available in html format only.

Harrier — Mareeba, Qld 23 March 2002

Extract: "The aircraft suffered a massive inflight structural failure almost certainly caused by severe aileron flutter and the aircraft speed in the dive. Any flutter would have been exacerbated by the lack of mass balancing."

The accident report is available in MS Word format only.

Drifter — Aramac, Qld 30 July 2003

Extract: "He had held a valid AUF Pilot Certificate from December 2001, correctly endorsed for the aircraft type and he was operationally current. However there is no record of him undertaking any specialised low level training and he was relatively inexperienced for the operation in which he was involved."

The accident report is available in MS Word format only.

RANS Coyote – Holbrook, NSW 5 July 2003

Extract: "RA-Aus must continue to educate pilots on the inherent dangers of low flying, the risks of poor decision making and the obvious fatal penalties for failing to observe the basic rules governing aviation."

The accident report is available in html format only.

Chinook WT II — Bellford, NSW 31 May 2003

Extract: "The (unauthorised) pilot having somehow become airborne was confronted with either trying to out climb the trees on take-off or attempting a 'go-around' after an abortive approach. In his attempts to climb over the trees he has pulled the aircraft into a near vertical attitude from which it has stalled and performed a tail slide backwards into the trees impacting the branch which became attached to the aircraft, the machine then fell to the ground nose first."

The accident report is available in html format only.

Capella — Gapsted, Vic 3 Nov 2002

Extract: "The wind direction and strength combined with the topography at the accident site would have combined to produce a small standing wave with the downwash just to the south of where it is indicated that the wing tip was found. An aircraft approaching at minimum speed and tree top height could expect significant sink in that area! This could translate to loss of speed if the pilot was concentrating solely on touching down on a given spot."

The accident report is available in html format without images but an Adobe Acrobat version with photographs is also available.

RA-Aus Accident Investigations