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.