ASN Wikibase Occurrence # 270937
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Date: | Sunday 19 December 2021 |
Time: | 09:08 |
Type: | Rockwell Commander 114 |
Owner/operator: | Private |
Registration: | VH-WMM |
MSN: | 14229 |
Year of manufacture: | 1977 |
Total airframe hrs: | 3431 hours |
Engine model: | Textron Lycoming IO-540-T4A5D |
Fatalities: | Fatalities: 4 / Occupants: 4 |
Aircraft damage: | Destroyed, written off |
Category: | Accident |
Location: | near Redcliffe Airport (YRED), QLD -
Australia
|
Phase: | Initial climb |
Nature: | Private |
Departure airport: | Redcliffe Airport, QLD (YRED) |
Destination airport: | Redcliffe Airport, QLD (YRED) |
Investigating agency: | ATSB |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:A Rockwell Commander 114, registered VH-WMM, departed Redcliffe, Queensland for a private flight. On board were a pilot and 3 passengers. Shortly after take-off, the engine lost power and the pilot elected to return to the airfield. During the return, the aircraft lost altitude and impacted the ocean before becoming inverted. The occupants were unable to escape the aircraft and were fatally injured, and the aircraft was destroyed.
Contributing factors
- An unsafe condition was created by not referring to the approved checklists in the pilot operating handbook. Checklists located in the pilot operating handbook would have prompted the pilot on 3 occasions to set the fuel selector to BOTH prior to take-off.
- A perceived engine problem distracted the pilot during the conduct of pre-take-off checks. After rectifying the issue, they did not complete the remaining pre-take-off checks (including fuel tank selection) before departure.
- A fuel imbalance and likely an incorrect fuel tank selection prior to take-off, led to fuel starvation and engine stoppage soon after take-off.
- The pilot, likely experiencing the effects of stress and time pressure following the engine power reduction and then stoppage, did not conduct initial emergency actions and attempted to return to the runway for landing but did not maintain glide speed, and the aircraft impacted shallow water prior to reaching the airfield.
- During the return to the airfield, the pilot extended the undercarriage, contributing to the aircraft inverting when it collided with water. This likely resulted in occupant disorientation, difficulty in operating the exits, and reduced their ability to escape.
Other factors that increased risk
- It is very likely that the passengers did not receive pre-flight information about the brace position or what to do in the event of a ditching. In the limited time available inflight after the power loss, the pilot also did not provide an emergency briefing or any instructions to passengers prior to impact with the water.
- While the pilot was primarily responsible for the operation of the aircraft exits in an emergency, seating a child, who may require assistance, adjacent to an exit instead of an adult meant that a less suitable passenger was available to operate the exit if required.
- The pilot had a diagnosed type 2 diabetic condition and did not directly declare this to the DAME during multiple medical renewals.
Accident investigation:
|
| |
Investigating agency: | ATSB |
Report number: | AO-2021-053 |
Status: | Investigation completed |
Duration: | 2 years and 2 months |
Download report: | Final report |
|
Sources:
https://www.brisbanetimes.com.au/national/queensland/four-killed-as-light-plane-crashes-into-wetlands-off-redcliffe-20211219-p59isg.html https://www.abc.net.au/news/2021-12-19/plane-crashes-into-ocean-near-brisbane/100712252 https://www.atsb.gov.au/publications/investigation_reports/2021/aair/ao-2021-053/ https://live.staticflickr.com/1469/23657911113_99d0229c67_h.jpg (photo)
Media:
Revision history:
Date/time | Contributor | Updates |
19-Dec-2021 03:06 |
Geno |
Added |
19-Dec-2021 05:20 |
RobertMB |
Updated [Aircraft type, Registration, Cn, Operator, Location, Phase, Nature, Departure airport, Destination airport, Source, Damage, Narrative] |
19-Dec-2021 12:16 |
Aerossurance |
Updated [Embed code, Narrative] |
19-Dec-2021 13:33 |
johnwg |
Updated [Embed code, Category] |
20-Dec-2021 11:57 |
Captain Adam |
Updated [Location, Source, Damage, Narrative] |
23-Dec-2021 08:34 |
RobertMB |
Updated [Source, Narrative] |
05-Apr-2022 15:31 |
Captain Adam |
Updated [Time, Narrative] |
14-Mar-2024 06:56 |
ASN |
Updated [Narrative, Accident report] |
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