The 22 March 2014 accident occurred when the aircraft was conducting tandem parachuting operations at Caboolture in Queensland. On board were the pilot, two parachuting instructors and two tandem parachutists.
Shortly after take-off, the aircraft climbed to about 200 feet before aerodynamically stalling and colliding with the ground. Tragically, all five died in the accident.
ATSB Chief Commissioner Greg Hood said the investigation report, released today, reveals that extensive fire damage prevented examination and testing of most of the aircraft components.
“Due to the post-impact damage to the aircraft, we couldn’t rule out a mechanical defect as a contributor to this accident,” Mr Hood said.
“Importantly, our investigation did uncover a number of safety issues associated with occupant restraint, modification of parachuting aircraft and scope for improving the risk controls associated with parachuting operations.”
In response to the ATSB’s investigation, the Australian Parachute Federation (APF) and Australia’s aviation safety regulator, CASA, undertook action to improve safety of parachuting operations.
“The APF mandated that all member clubs/operations have their own safety management system to proactively assess and mitigate risks. The APF has also enhanced their audit process and increased the number of full-time safety personnel to audit their member organisations.” Mr Hood said.
“The Civil Aviation Safety Authority (CASA) has increased the available information on their website about the risks associated with sports aviation. CASA also introduced an Airworthiness Bulletin to provide guidance about co-pilot side flight control modifications.
“We welcome APF’s and CASA’s safety action but consider more can be done to improve safety for skydiving operations.”
In response to an identified safety issue, the ATSB recommends that CASA take safety action to increase the fitment of the Cessna secondary pilot seat stop modification. This safety issue affects all Cessna Aircraft and not just those being used for parachuting operations.
In addition, it is recommended that CASA introduce measures to reduce the risk associated with the aviation aspect of parachuting operations.
As well, the ATSB recommends CASA and the APF increase the use of dual-point restraints in parachuting aircraft.
Under legislation, APF and CASA have 90 days to respond to the ATSB’s recommendations.
Read the full investigation report AO-2014-053