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Cessna 210 Crash Moruya Airport 19 December 2019


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Even with the gear and flaps out I would guess about 1.5nm per 1000' or 4000metres to touch down. We also don't know what the wind was. Only a lot of practice will make perfect.

 

 

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Yes it looks like a textbook forced landing, over the strip at 1500, just wash off the height & grease it on. It was reported the wind was gusting to 40 knots  (direction unknown) & it was hot. The 210 has a glide angle of 8:1 or even less at 85 knots flaps up. so at 1500 feet he has a maximum of about 3.5km in still air. With a gusty 40knot headwind make that 1.7km. Even if the wind was not on the nose working out the options with only 1.5 minutes of flight time left with your brain in meltdown phase what decision do you make. The approach was too high for 04 which is short at 827 metres so decided to go for 18, at 1523 metres, much better. By this time he'd be below 1000 feet & possibly turning into a headwind. In the end he did the best he could, landing straight ahead. Turning back to try to get to 18 would have been the worst decision he could have made at that stage.

 

 

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I find it rather amusing that there are quite a few in this thread that seem to think that it would be just so easy to land perfectly on the runway, there are so many factors that would determine the outcome of this situation, the cloud at Moruya has been very frequent of late, the smoke from close by fires, wind, prop may not have feathered, unfamiliar runways and terrain.

 

If there was cloud or smoke on the day he may have had little time to actually see the unfamiliar runways to judge his position and altitude, if the pilot was flying around the world I would assume he was quite experienced, I would also like to know if the few on this thread that seem to think it would be so easy to land and just walk over to the maintenance shop for repairs, how many have deadsticked a turbined P210 at Moruya

 

 

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Hence why I said I am really keen to know why and how he ended up where he did.  Maybe we can all learn from it.

 

That's the sad thing...  A lot of the time the pilot does not survive, so we never know.  But when they do, we rarely here exactly what went down and why.  I think it's a goldmine of education right there!

 

 

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You will probably get to know, sometime. Nev

 

They probably will since ATSB have already posted the file. Nothing useful on it yet but they’ll dissect the way down.

 

 

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Ended up where it did because we are all human and not perfect, not one of us, only the pilot knows why he misjudged the force landing, at the end of the day he is alive and that’s all that matters for him and his passenger.

 

 

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Apart from pilot incapacitation this is a monumental fail. There are so many 'accidents' that are simply caused by pilot incompetence. I have seen it and examined it many times. We have to accept and realize that we are operating in an unforgiving environment. So many of us think that if a flight goes well in good conditions, that makes us a good pilot. No it doesn't. What makes us a good pilot is being able to handle a given circumstance when things aren't going well. That can be as simple as calling off a flight before getting airborne, but usually it is having to handle something unexpected and potentially life threatening after the throttle is pushed fully forward. All of us need to spend whatever time necessary to become competent in all areas but particularly in X winds, forced landings and precision landings. If you don't fly regularly you can never be competent in these areas. If you do fly regularly but don't practice these skills you will not be competent. In this incident two people have been injured, and a beautiful aircraft probably written off. This equates to much suffering and cost. If anyone is asking 'what is competent', my definition is not feeling panic, undue stress or fear when faced with what in aviation, happens all the time!!

 

ifrduck

 

 

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Apart from pilot incapacitation this is a monumental fail. There are so many 'accidents' that are simply caused by pilot incompetence. I have seen it and examined it many times. We have to accept and realize that we are operating in an unforgiving environment. So many of us think that if a flight goes well in good conditions, that makes us a good pilot. No it doesn't. What makes us a good pilot is being able to handle a given circumstance when things aren't going well. That can be as simple as calling off a flight before getting airborne, but usually it is having to handle something unexpected and potentially life threatening after the throttle is pushed fully forward. All of us need to spend whatever time necessary to become competent in all areas but particularly in X winds, forced landings and precision landings. If you don't fly regularly you can never be competent in these areas. If you do fly regularly but don't practice these skills you will not be competent. In this incident two people have been injured, and a beautiful aircraft probably written off. This equates to much suffering and cost. If anyone is asking 'what is competent', my definition is not feeling panic, undue stress or fear when faced with what in aviation, happens all the time!!

 

ifrduck

 

The ATSB report will probably tell us what went wrong.

 

However, if you haven't flown a big, heavy six place aircraft with C/S, RUC, a load of talking passengers and several complications, it's not really possible to understand what the pilot shold have done and when. There's a saying in this class "You have to stay ahead of the plane", and MANY people have shown they can't. At one stage this airctraft was reported as gliding down at 1000 ft/min, so even forced landings have a totally different dimensions. I've certainly lost sight of my selected field on the way down just due to the type of aircraft these are, so it's not surprise to me that when it got close the approach would be nowhere near as accurate as is would be for a Jab from 1000 ft. It could even have been that the hydraulic systems with the different engine caused problems setting up towards the end. The goo thing with this one is the ATSB is likely to be able to tell us based on the pilot's explanation.

 

 

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The ATSB report will probably tell us what went wrong.

 

However, if you haven't flown a big, heavy six place aircraft with C/S, RUC, a load of talking passengers and several complications, it's not really possible to understand what the pilot shold have done and when. There's a saying in this class "You have to stay ahead of the plane", and MANY people have shown they can't. At one stage this airctraft was reported as gliding down at 1000 ft/min, so even forced landings have a totally different dimensions. I've certainly lost sight of my selected field on the way down just due to the type of aircraft these are, so it's not surprise to me that when it got close the approach would be nowhere near as accurate as is would be for a Jab from 1000 ft. It could even have been that the hydraulic systems with the different engine caused problems setting up towards the end. The goo thing with this one is the ATSB is likely to be able to tell us based on the pilot's explanation.

 

Spot on!

 

 

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Apart from pilot incapacitation this is a monumental fail.

 

This is just a silly statement without knowing any of the circumstances, as I said in my earlier post there are so many variables that would determine the outcome of this incident.

 

I do agree with the remainder of your post though

 

 

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Two INJURED foreign nationals and a foreign registered aircraft are worthy of an ATSB investigation.

 

https://www.atsb.gov.au/publications/investigation_reports/2019/aair/ao-2019-075/

 

Yet Australian citizens and taxpayers DIE in recreational aircraft crashes and no one gives a hoot......

 

 

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Two INJURED foreign nationals and a foreign registered aircraft are worthy of an ATSB investigation.

 

https://www.atsb.gov.au/publications/investigation_reports/2019/aair/ao-2019-075/

 

Yet Australian citizens and taxpayers DIE in recreational aircraft crashes and no one gives a hoot......

 

The Coroner does, and in terms of finding out the cause of death the pilot probably gets equal treatment; it's just that the reports are not always easy to find.

 

 

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Actually, the ATSB DOES investigate recreational aircraft accidents, or provide technical support, if they are contacted. The problem is that RAAus is responsible for investigating the accidents for aircraft THEY administer, so unless they ask for assistance, ATSB generally won’t get involved, and in a lot of cases RAAus culture is to avoid getting the “big boys” involved. In fact, unless there is serious injury or a fatality, I suspect that most RAAus accidents/incidents are swept under the carpet by the aircraft owner/pilot. This also happens in GA at a recreational level. I know of 3 GA accidents in recent history that have resulted in total loss of aircraft, one was a fatality the other 2 resulted in no significant pilot injury. Two are being investigated, the third is not. The difference is that ATSB were not contacted about the third accident. 

 

 

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It is mandatory to report any aviation incident involving transport safety to the ATSB, under Section 3 (sub-sections 18 and 19) of the Transport Safety Investigation Act 2003. Penalties are provided for not doing so.

 

"The ATSB is responsible for the independent investigation of accidents and incidents involving civil aircraft in Australia. The ATSB's primary focus is the safety of the travelling public. However, all accidents and incidents related to flight safety in Australia or involving Australian registered aircraft overseas must be reported to the ATSB. While the ATSB does not investigate all of these, it still needs to be notified so that the data can be recorded for possible future safety research and analysis. Please call the toll-free number 1800 011 034 to notify the ATSB of such accidents or incidents"

 

 

 

TSI Act 2003 - https://www.legislation.gov.au/Details/C2016C00617

 

ATSB - Enforcement policy - https://www.atsb.gov.au/about_atsb/legislation/enforcement-policy/

 

Note that ATSB investigation information cannot be used as evidence in any civil or criminal proceedings. ATSB investigation reports may only be used in coronial inquiries for the purpose of improving safety.

 

The terms of mandatory reporting are pretty clear. Note that the ATSB chooses whether to investigate or not, once a report has been lodged.

 

Section 23 of the TSI Act provides a list of Transport Safety Matters. These are the matters that the ATSB may investigate in the aviation, marine and rail modes of transport under Section 21.

 

Transport Safety Matters are:

*  the transport vehicle being destroyed or damaged;

* the transport vehicle being abandoned, disabled, stranded or missing in operation;

* a person dying as a result of an occurrence associated with the operation of a transport vehicle;

* a person injured or incapacitated as a result of an occurrence associated with the operation of the transport vehicle;

* the transport vehicle being involved in a near-accident;

* any property damaged as a result of an occurrence associated with the operation of the transport vehicle;

* the transport vehicle being involved in an occurrence that affected, or could have affected, the safety of the operation of the transport vehicle; and

* something occurring that affected, is affecting, or might affect transport safety.

 

 

 

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Actually, the ATSB DOES investigate recreational aircraft accidents, or provide technical support, if they are contacted. The problem is that RAAus is responsible for investigating the accidents for aircraft THEY administer, so unless they ask for assistance, ATSB generally won’t get involved, and in a lot of cases RAAus culture is to avoid getting the “big boys” involved. In fact, unless there is serious injury or a fatality, I suspect that most RAAus accidents/incidents are swept under the carpet by the aircraft owner/pilot. This also happens in GA at a recreational level. I know of 3 GA accidents in recent history that have resulted in total loss of aircraft, one was a fatality the other 2 resulted in no significant pilot injury. Two are being investigated, the third is not. The difference is that ATSB were not contacted about the third accident. 

 

ATSB has investigated RAA accidents where there was a clear public benefit - eg the Ferris Wheel incident (no fatalities).  RAA have approached ATSB for more investigations, however they have a budget, and until their political masters see the benefit in increasing their staff etc to cover RAA fatalities and accidents, it is not going to happen.

 

I read a fair bit of RAA bashing over reporting accidents, and a fair bit of people not reading or understanding the present situation.  When a fatality occurs, the Police are the lead agency to investigate and prepare a report for the Coroner who then releases his/her findings.  As Turboplaner says, some Coroner's reports can be hard to find.  While the investigation is on-going RAA & others, are restricted in what they can reveal.

 

It is up to the Police to request RAA to help with the investigation.  In times past they have refused, and that left RAA to stand in line with the rest of us waiting a year or two for the Coroner's report.  To counter that, RAA sent their investigators to the ATSB course in accident investigation, so that their reports would carry more weight.  Police now seem to be more willing to request RAA assistance.  Some times RAA requests ATSB assistance with technical issues (eg retrieving data from flight instruments), and I suspect we pay for that.

 

As for Sweeping it under the Carpet - ATSB sometimes declines to investigate - two GA friends of mine had wheels-up landings, one was the subject of an ATSB report and the other was not (but CASA had something to say to him). 

 

RAA has an occurrence log where you can list the details of accidents, incidents, near misses etc.  If you see something wrong you can report it.  You don't have to be the pilot.  You can be anonymous, and our Club has had two of these from non-pilots, reporting suspect behaviour.  A recent accident, the pilot tried to make out it wasn't his fault, but several pilot witnesses told RAA otherwise and he was suspended pending re-training.  The system isn't perfect, never will be, but it is loads better than it was 10, 20 years ago.

 

 

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  • 3 weeks later...
Before the speculation runs too rampant as it has elsewhere... (Please avoid judgement also, the pilot and passenger were airlifted to Canberra Hospital, the last thing they need right now is negative thoughts).

 

The facts are:

The flight was from Bankstown to Cambridge (Hobart) cruising at FL160. Approx 20nm past Moruya the engine failed, they were losing 1000fpm. The aircraft was pressurised, it was a P210N model. The aircraft had a turboprop, not piston motor. From this height they were able to make it back to Moruya, but had about 2 minutes at most near the airport to assess the situation/airfield and make their decision (which in the heat of the moment would go very quickly, and keep in mind a normal circuit does take around 6 minutes). They chose to attempt an approach onto 04, however were too high and too close so quickly switched to a circuit onto 18, unfortunately they weren't able to make the final turn and instead of attempting a low level steep turn they chose to put it down straight ahead into the overshoot scrub. The wind throughout the day was gusting to around 40kts and it was hot (so people were at the beach).

 

Moruya can be a tricky airfield, it does have its characteristics that can catch people off guard, an example being unexpected sink near the river, and when it's windy it can be a challenge due to the terrain & mechanical turbulence.

 

Given the amount of practice forced landings I've done at Moruya, I think the pilot has done a good job under pressure and whatever decisions they thought were right has ultimately saved their lives (and that's all that matters, aircraft can be replaced), although they probably will be spending Christmas in Canberra Hospital. Hoping they have a speedy recovery.

 

As the PIC, you are spot on.

 

The ADS-B data cuts out a bit early, and is showing lower altitudes than the logs recovered from onboard, but is directionally accurate.

 

We had an unrecoverable engine failure at FL160, that the ATSB, NTSB and Rolls Royce are still trying to determine the cause of.

 

ATC immediately responded to the Mayday call, and vectored us to Moruya, and notified an EMS helicopter. We arrived over the field at around 9000ft for the first orbit and set up for 34. On final for 36, heard a R44 on the CTAF who said they were on 18 and the winds favored 18. 

 

 

We did not have the R44 in sight at 1300ft, so made the call to try for 18, and try and see the traffic. The Silver Eagle with feathered prop glides at better than 19:1, so the instant decision was to abandon 36 try for 18 rather than land without traffic in sight and with a tailwind, and no reverse available.

 

We lost 400 ft crossing the river, and we’re at marginal height on downwind for 18, when we turned base then final we had higher than expected gusts and at 200ft, decided as slow as possible and short was best for the people on board, as opposed to trying to up flaps and maybe get closer to 18 but have a higher ground speed.

 

As it turned out, my passenger walked away, and I had some broken legs and superficial stuff. 

 

 

Lessons learned: 

 

I had well over 200 hours in that aircraft, but how hard she was to loose altitude with a feathered prop, even with everything down and hanging was a surprise. 

Second would be if you are a Mayday and you hear but can’t see conflicting traffic, get on the radio and tell them to get the hell out of your way.

 

In the end, I wouldn’t trade the result, excellent assistance from ATC, NSW Ambulance, the Australian Army, and a gun team of doctors at Canberra hospital who helped put humbly dumpty together again.

 

 

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Firstly - I am glad you are OK.  Would have been scary as hell.  That said, personally, bugger the traffic you can't see.  That's their problem - they had power, you didn't.  But I guess, like you said, lesson learnt!

 

Can I ask if sideslipping had any affect on getting her sinking??

 

Anyways... like I said man... Thank goodness you are Ok - of sorts.

 

 

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Certainly this gentleman made the best of a bad situation and did not succumb to the powerful temptation  to 'glide stretch' which usually is fatal.

 

Unexpected emergencies in flight are very un-nerving.  The only way to overcome the stress and panic from these events is practice and familiarity. This is very much the case with VFR into IFR, and engine failures. Most pilots after a little practice with a qualified instructor and equipped aircraft, can do a reasonable job of straight and level, rate 1 turns, and can keep enough mental capacity for a scan to save themselves in cloud by doing a 180 and flying back out of cloud to live another day. However, take away the instructor; and the little bit of basic IFR done many moons ago is worth nothing when all of a sudden the pilot who is somewhere he should never be anyway, scud running or pushing last light enters cloud, with rain or low terrain or turbulence, and the result is nearly inevitable. IFR is a good example because experience has shown that only constant practice and checking keeps you proficient and safe, and the rules reflect this. Unless you are familiar with a procedure, an emergency will turn your brain to porridge! I have experienced this in IFR, as well as engine failures, and can attest to this phenomena! I was practicing engine out procedures in an aircraft that was supposed to have a 17:1 glide ratio with the prop feathered. Before I became familiar with this aircraft I thought, "how could you go wrong". I quickly found that the serene decent became very critical and scary near the ground as I nearly always underestimated my glide performance. Added to that was probably the fact that with the checking and other cockpit drills my speed control was tardy, and only God could achieve the 17:1 quoted by the manufacturer.  It took me a lot of practice in a number of prop and gear configurations to feel confident  with an engine failure in that aircraft. Today I still regularly practice engine failures and cross wind landings in all configurations to stop the 'porridge,' when the unexpected happens. I always aim to be 'high' on finals. The old adage of running out of strip with 20knots on the clock is still much better than 'landing' short at 60+knots. I have been flying all my life and I find I can still 'stuff it up' unless I regularly refresh these skills.  I would be amazed if any 210 could achieve a 19:1 glide ratio. I think that figure needs checking having flown many 210s over the years. Maybe with the angel Gabriel as a passenger!  So don't just 'expect the unexpected', as CASA says, practice and practice and PRACTISE for it!! Safe Flying. T.N.

 

 

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Firstly - I am glad you are OK.  Would have been scary as hell.  That said, personally, bugger the traffic you can't see.  That's their problem - they had power, you didn't.  But I guess, like you said, lesson learnt!

 

Can I ask if sideslipping had any affect on getting her sinking??

 

Anyways... like I said man... Thank goodness you are Ok - of sorts.

 

Thanks, surprisingly not scary, it’s amazing how those emergency drills and practice just kicks in.  If I ever have another 1 in a million turboprop events, I certainly won’t be shy in telling traffic to GTFO.

 

Side slipping worked great to get me from 9000 to 1600 or so in one orbit. If we had committed to 36 we could have dumped height easily. It is unnatural to cross control with no engine though, just felt wrong.

 

I’ll take OK - of sorts over the alternative any day, the key was my passenger was fine. That was what I was most concerned about.

 

 

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Better than 19:1 is a very impressive L/D and is approaching sailplane specs. It this a correct value?

 

It is the book value, that frankly I always thought was overstated. I was actually doing better than that with gear down and 10 flaps.

 

Now I am a believer.

 

 

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