Post on 21-Feb-2017
Loss of control and collision with water; Private operated;
Cessna Aircraft Company C210H VH-EFB
160 km south-west of Darwin, Northern Territory, 1st April 2013
Contents
1.0 Factual information ..................................................................................................... 3
1.1 History of the flight .............................................................................................. 3
1.2 Injuries to persons ................................................................................................ 6
1.3 Damage to aircraft ................................................................................................ 6
1.4 Personnel information .......................................................................................... 6
1.5 Aircraft information ............................................................................................. 7
1.6 Meteorological information ................................................................................. 8
1.7 Aids to navigation ................................................................................................. 9
1.8 Communication .................................................................................................... 9
1.9 Wreckage and impact information ................................................................... 10
1.10 Survival aspects .................................................................................................. 10
2.0 Analysis ....................................................................................................................... 10
2.1 Software ............................................................................................................... 10
2.2 Hardware ............................................................................................................ 11
2.3 Environment ....................................................................................................... 12
2.4 Liver ware ........................................................................................................... 14
2.5 Liver (others) ware ............................................................................................. 15
3.0 Conclusion .................................................................................................................. 16
4.0 Safety recommendation ............................................................................................. 18
5.0 Bibliography ................................................................................................................. 21
1.0 Factual information
1.1 History of the flight
Figure1.1: Weather radar image as of 1205
Source: Bureau of Meteorology and ATSB
On 28 and 29 March 2013, a group of pilots (including the pilot of Cessna
210 VH-EFB which was the only one Cessna 210 in this group) flew aircrafts
from Emkaytee (near Darwin) to Bullo River and planned to fly back at 1st
April 2013. However, the weather in 1st April’s morning was not good and
had low cloud with rain between Emkaytee and Bullo River which was not
suitable for flight under Visual Flight Rules (VFR). (CASA, 2010) Therefore,
the pilots had to delay the flight and waited for the weather improving. In
the afternoon of that day, the weather became better but still rained on their
track (Figure 1.1). The pilots discussed together and decided to fly back at
around 1400. Every pilot began to make their own flight plan and did the
pre-flight check. There were three pilots (including the pilot of VH-EFB)
planned track coastal (which was Bullo River – Wadeye – Dundee Beach -
Emkaytee) and others made direct tracks. At around 1400, this group of
pilots began to depart from Bullo river airstrip one by one. The VH-EFB
which carries one pilot and three family members departed at about 1415
and all aircrafts had departed by 1500. (Depending on what other pilots in
the group said)
During their flight, the pilots used a discrete radio frequency (cannot be
recorded) so that they could connect with others clearly and share weather
information they saw. The pilots of direct tracks found that the weather was
suitable for visual flight and flew breezily.
At about halfway, the pilots found that there was an area of low cloud and
rain in storms moving towards their direct track. However, all of the direct
tracks’ aircrafts had flied pass that dangerous area before the storms arrived.
On the other hand, the weather of the coastal track became increasingly
worse (Figure 1.2). One of three coastal track aircrafts changed to direct
track when founding the weather was turning worse. Another aircraft found
a gap of the storms, bypassed the storms and continued the coastal flight.
Figure 1.2: Weather radar image at 1505
Source: Bureau of Meteorology and ATSB
At about 1510, other pilots received the message from VH-EFB that BH-
EFB was approaching Cape Ford at 500 ft and the weather ahead was
gloomy. The pilot sound did not distress at that time as other pilots claimed.
This was the last message other pilots got from VH-EFB. (Retold by a
number of other pilots in the group because the communications on that
discrete radio frequency were not recorded)
After all of other aircrafts arrived at Emkaytee, the pilots found that VH-
EFB was lost. Therefore, some pilots notified the search and rescue
authorities and departed by aircrafts to search for VH-EFB. However, the
weather around Cape Ford became worse by the continuing storms which
made the searching by aircraft impossible. Thus, the searching was resumed
to the next morning. On the next day, some bodies and wreckage from VH-
EFB were found on the southern part of Arson Bay where was 10 km south-
east of Cape Ford. There were no survivors. No further information until
October 2013 that some other wreckage of VH-EFB was found 2 km away
from the occurrence.
1.2 Injuries to persons
Figure 1.3: persons’ injuries
Crew Passengers
Total Persons on board 1 3
Fatal 1 3
1.3 Damage to aircraft
The aircraft was totally destroyed.
1.4 Personnel information
The VH-EFB pilot had owned the aircraft for just over 12 months and had
flown by this aircraft about 300 hours which include two wet seasons’ cross-
country flight. The pilot had Private Pilot License which issued April 2010
and Class 2 Medical Certificate which valid to October 2013. However, the
pilot did not hold an instrument rating and only had 3-hour instrument flying
experience three years ago.
Depending other pilots’ statement, the pilot of VH-EFB had a good and
enough sleep before the day of the accident. In addition, this pilot did not
show any stressful emotion during the pilots’ weather discussion before the
flight.
Figure 1.4: Pilot information
Source: (ATSB, 2013)
1.5 Aircraft information
The previous owner of this Cessna 210 VH-EFB reported that the aircraft
was reliable, relatively fast and was sensitive in pitch which meant that the
aircraft could lose height fast. In addition, the only recent maintenance issue
for VH-EFB was a hydraulic oil leaking of landing gear which also shown
that this aircraft was reliable.
The VH-EFB was equipped with an attitude indicator, vertical speed
indicator and directional indicator which had reached the requirement of
VFR-category operations. However, this aircraft was not certified for flight
in instrument meteorological conditions.
The VH-EFB was reported that it refueled to full tanks before departed from
Bullo River which meant that the aircraft could fly 5.5 hours maximum
without using reserve fuel (the flight from Bullo River to Emkaytee costs less
than 2 hours).
Figure 1.5: Aircraft information
Source: (ATSB, 2013)
1.6 Meteorological information
From Figure 1.1, Figure 1.2 and Figure 1.6, it could be seen that the weather
around Cape Ford (which was included in coastal track) was turning worse
during the flight. This area was full of low cloud and rain with storms which
would reduce the visibility; full of low level wind and moist unstable
atmosphere which made the aerodynamic unstable, turbulence and wind
shear could happen at any time.
Figure 1.6: False-colour infrared satellite image at 1500
Source: Bureau of Meteorology
1.7 Aids to navigation
The VH-EFB was equipped with an autopilot which provided lateral control
which could control the aircraft’s heading hold, but no pitch or altitude
control.
1.8 Communication
The VH-EFB had a portable Global Positioning System (GPS) which could
help the pilot realized his location easily. Depending on other pilots in the
group’s statement, the GPS worked well and the signal was stable during
their flight.
On the other hand, none of these pilots had connected the Bureau of
Meteorology (BOM) which had more advanced equipment for reporting
more accurate weather forecast and was available to all aviators for detailed
weather report.
1.9 Wreckage and impact information
Some wreckage including the pilot’s damaged flight bag was found after the
day of the accident. Most of the wreckage were useless because they were
totally damaged by overstress. 20 per cent of fragments of the battery case
was tested and showed no evidence of any material or electrical anomalies.
In October 2013, some additional wreckage such as wings, fuselage, seats,
engine and propeller was found 2 km away from the first part of wreckage
position. The tests of the wreckage show that there was a high degree of force
in the collision with water.
1.10 Survival aspects
The pilots in the group departed again to find the VH-EFB after they found
that the aircraft was lost, but they were forced to return because the weather
became worse and not suitable for flight. The survival aspects also delayed
to the next day after the accident because of the terrible weather.
2.0 Analysis
2.1 Software
The autopilot system of the VH-EFB could only control the lateral which was
used to control the aircraft’s heading hold. Therefore, this simple autopilot
system cannot control the aircraft efficiently when the aircraft meet the
turbulence and loss of control if the pilot loses the judgment of the aircraft’s
altitude.
2.2 Hardware
Sensitive in pitch
According to the previous owner’s statement, the VH-EFB was sensitive
in pitch. Therefore, the aircraft could lose height immediately if the
aircraft met suddenly turbulence and the pilot did some ultra-operations.
However, because the pilot of VH-EFB had flown this aircraft over 500
hours including two wet seasons flight, the pilot should know about this
flight quite well and ultra-operations does not show a high possibility.
No recorder and black box
Because the VH-EFB was a private aircraft, there were no recorder and
black box on the aircraft. Without recorder and black box, investigators
could hardly get what the pilots said and the attitude of the aircraft before
the accident. In addition, in case of interference, this group of pilots used
a discrete radio frequency which could not be recorded. It also made
investigators harder to get the accurate communications by only retold
from other pilots, because human can hardly remember all of the details
of the communication, especially when they were focusing on flying in
bad weather. For example, some words they believe not important, the
sound of warning system came from other aircrafts and some suddenly,
short and strange sound.
Not certified for flight instrument
This Cessna 210 did not have certification for flight instrument.
Therefore, if this aircraft flies into the area which is not suitable for
visual flight by accident, the pilots may get disoriented and the risk of a
crash will increase much.
2.3 Environment
Low visibility
The accident area was full of cloud which made the pilot of VH-EFB
hardly to see the forward situation. In the last report of the VH-EFB, the
pilot claimed that he had to reduce the height to 500 ft which is the lowest
height that aircrafts could fly according to Visual Flight Rules (VFR)
(CASA, 2010). It supports that the environment at that time was quite
terrible and the visibility was quite low. Even though the VH-EFB was
flying towards coastal track and had much less opportunity to meet
elevated terrain, it is still quite dangerous flying in a much low visibility
area.
Similar color for sky and surface
From Figure 2.1, it could be seen that distinguishing between surface
and sky and finding out the horizon are almost impossible with low cloud.
The views of the pilots in aircrafts will be more unclear that these
pictures. When the pilots fly in an area where is lack of reference, such
as night without moonlight and above the water with low cloud, the
pilots could easily get disoriented and lose the judgment of the flight
attitude. From Figure 2.2 it could be seen that if the aircraft flies towards
the surface, even the pilots have good skills on instrument flight, without
autopilot system, they cannot judge the flight altitude through
instruments.
Figure 2.1: the sea and sky with cloudy weather
Source: google image
Figure 2.2: Special situation of Attitude indicator
Normal Loss of control Towards surface (out of limit)
Source: (Air Crash Investigation, 2003-present)
2.4 Liveware
Lack of instrument flight skill
As reported, the VH-EFB had enough equipment for basic instrument
flight. Thus, even if the pilot got disoriented, he should have the ability
to control the aircraft’s for basic flying. However, the pilot of VH-EFB
did not have instrument flight rating and had only done instrument flight
in 3 hours three years ago. Three hours instrument flight experience
could only give the pilot a short term mammary about it. The pilot could
forget it quickly in a short time without any review. Therefore, with the
three years without any review, the pilot possible already totally forgot
about instrument flight.
Choose a flight track with less pilots flew
Most of the pilots in the group chose to fly direct to Emkaytee but only
three pilots chose the coastal track including one pilot who changed the
route to direct track in the halfway. Thus, there were only two aircrafts
flew in the coastal track, in fact. All of these situations made the VH-
EFB flew quite lonely. Even though all of the pilots in the group was
talking in same radio frequency, the shared messages were most about
the direct track. Therefore, the pilot of VH-EFB could get quite less
information about the environment ahead and surrounding him.
Flew too low
According to other pilots in the group statement, the last message from
the VH-EFB claimed that he had to reduce to 500 ft because the weather
forward was gloomy. 500 ft is a quite low level for flight. The aircraft
may crash the surface in 10 seconds with a losing of control. In addition,
because of the similar color between surface and sky, the pilot may lose
the judgment of the flight attitude for some seconds with a sudden
turbulence. Therefore, the pilot could hardly find out what happening
and re-control the aircraft’s flight attitude in about 10 seconds.
Had not connected BOM
As reported before, the BOM is free to all pilots for asking environment
message, but none of the pilots in the group made it. If they asked BOM
and got a more detailed weather report, they may realize that the weather
of the coastal track would turn worse later and totally chose the direct
track which could lead all of them flew back safety.
2.5 Liver (others) ware
Lack of communication
During the flight back to Emkaytee, the pilots in the group only
communicated about the environment around them but did not confirm
if each others were flying safety. It led to that no one realize the VH-
EFB was missed until all of other pilots had arrived Emkaytee. If the
pilots in the group confirmed each others’ safety, they may found out the
missing message earlier and notify the research and rescue authorities
earlier before the weather at Cape Ford became too worse for flying. The
pilot and passengers might be survived.
Search for the VH-EFB without permission
When other pilots in the group found the VH-EFB was missed, some of
them departed from Emkaytee to find VH-EFB. This action is quite
dangerous. The weather of Cape Ford area was turning worse and worse.
So, other aircraft possible got another accident without any survival
experience. It would increase the survival department’s stress and would
affect the survival much.
3.0 Conclusion
According to the analyzing, the cause of this accident could be concluded as
follow:
Flew into cloud and flew too low
The pilot of VH-EFB had chosen a not wise track and flew into low cloud area
which forced the aircraft reduce the height to get a clearer view. However,
because the aircraft flew in such a low level which made the pilot did not have
enough time to save the aircraft after it loss of control.
Met turbulence and forced landing fail
The pilot may try to make a forced landing on the water when the aircraft loss
of control by turbulence or the weather turned too bad for continuing flying.
However, because the pilot was lack of the skill of forced landing on the water
or the aircraft met suddenly turbulence just before it reached the water, the
aircraft crashed the water heavily. The high degree of force made the aircraft
breakup and also killed the passengers on board.
Lost the judgment of water and surface
As Figure 2.1 shows, the pilot of VH-EFB may get disoriented when flew
above the water with low cloud. At that time, the aircraft met turbulence which
forced the aircraft change the flight attitude and towards the water. However,
because the color of sky and water was quite similar, the pilot of VH-EFB did
not realize the aircraft was flying towards the water before it was too late. The
aircraft totally flew into water and breakup.
Pilot lack of instrument flight skill
The pilot of VH-EFB did not have enough experience and knowledge about
fly with instrument. Therefore, when the aircraft out of control, the pilot cannot
control the aircraft with the instrument ahead of him out of visual flight.
Finally, the aircraft crashed into water.
In-flight breakup
Because the second part of the wreckage was found 2 km away from the
occurrence, the aircraft may have an in-flight breakup. The aircraft may meet
turbulence which made the aircraft out of control. Because the pilot could not
control the aircraft back to normal flight attitude, the aircraft turned irregularly
in the sky and tore by the high speed wind went through the aircraft’s body.
Because of one or some of the factors above, the aircraft was finally break up and
collided with water.
4.0 Safety recommendation
Improve autopilot system (if possible)
The autopilot system could not only reduce the stress of pilots, but also save
the aircraft and passengers by some incidents. It is quite important because it
is the last defense of the aircrafts if the pilots cannot re-control the aircrafts by
some reasons. Therefore, complete autopilot systems are significant important
for safe aircrafts.
Add black box or recorder at least
There does not have rules for private aircraft to carry black boxes or recorders.
However, when an accident happens, the communication and flight altitude
are the direct evidence for the investigation. A recorder will not cost much
money but will increase the private aviation safety a lot by clearer investigation
reports and perfect accident defense system.
Train pilots more on flying with instrument
Flying with instrument is a situation often happens. Flying at night, flying in
bad weather and many other situations are all require the pilots have instrument
flight skills, especially for small aircrafts which do not have good autopilot
systems. Training pilots more time on instrument flight will increase the
aviation safety a lot.
Train pilots get used to use BOM
The pilots need to learn and get used to connecting with BOM for getting
weather report which could lead them get more detailed and correct weather
information for making safer flight plans. It will make the flight safer by
avoiding bad weather.
Train pilots for emergency landing
Emergency landing is an important skill for pilots especially for the old
aircrafts. The old aircrafts have more frequency to get problems comparing
with new ones, thus emergency landing may be needed at any time.
Systematically learning about where are suitable for emergency landings and
which flight altitude for landing on the water could damage passengers less
will minimum the dangerous and increase the survival rate a lot.
Propaganda the dangerous of flying above the water at low height
The pilots should realize all of the situation they may face when flying above
the water, such as flying with low cloud. They must learn that they may get
disoriented with low cloud above the water and what they should do when
disoriented happens to make the aircraft safety.
Teach pilots not to fly lonely in bad weather
When flying in a group, it is better to stay together than fly alone because pilots
could share information and the pilots could realize other aircrafts problem in
seconds. In addition, when a pilot in the group meet some problem, asking for
help and solutions are quick easy because other aircrafts are flying in the same
environment which makes the problem pilot does not need to claim a lot about
the problem. On the other hand, the pilots flying in a group may meet same
problems, thus they can discuss together to solve the problem. As all know,
group knowledge is much more powerful than one brain.
5.0 Bibliography
Air Crash Investigation. 2003-present. [Film] Directed by André Barro. Canada: Cineflix.
ATSB, 2013. ao-2013-063_final. [Online]
Available at: http://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-
2013-063.aspx
[Accessed 16 4 2014].
CASA, 2010. DAY (VFR) SYLLABUS - AEROPLANES. [Online]
Available at: http://www.casa.gov.au/wcmswr/_assets/main/fcl/download/vfrasfull.pdf
[Accessed 20 4 2014].
CASA, 2010. visual flight rules guide. [Online]
Available at: http://www.casa.gov.au/wcmswr/_assets/main/pilots/download/vfr/vfrg-
whole.pdf
[Accessed 20 4 2014].
CASA, 2011. TRAINING & EXAMINATION WORKBOOK for DAY VFR SYLLABUS. [Online]
Available at:
http://www.casa.gov.au/wcmswr/_assets/main/fcl/exams/cyberexam/day_vfr.pdf
[Accessed 20 4 2014].
Hollnagel, E., woods, d. D. & leveson, n., 2006. resilience engineering. In: concepts and
precepts. England: Ashgate Publishing Limited.