Investigation number
200001153
Occurrence date
Location
Shepparton, Aero.
State
Victoria
Report release date
Report status
Final
Investigation type
Occurrence Investigation
Investigation status
Completed
Aviation occurrence category
Collision with terrain
Occurrence class
Accident
Highest injury level
Fatal

The pilot of a Cessna 172M was conducting a private visual flight rules (VFR) flight, with two passengers, from Narromine to Shepparton. The passenger seated next to the pilot was also a qualified private pilot and the owner of the aircraft.

On arrival at Shepparton, the aircraft overflew the aerodrome. After noting from the aerodrome windsock that the wind was a moderate westerly, the pilot decided to use runway 18 for landing. The owner of the aircraft observed that the aircraft was high on the base leg and on final approach. He remarked that the pilot was having difficulty with the crosswind conditions, since the aircraft was drifting left during the landing attempt.

Witnesses noticed from several locations around the aerodrome that the aircraft was flying erratically 3 or 4 metres above the level of the runway, with a pronounced nose-up attitude. It was flying slowly and making apparently repeated attempts to touch down on the runway. Its height was varying slightly and its wings were rocking from side to side. This was confirmed by the pilot of a following aircraft who noticed that the Cessna 172 was only a few metres above ground level, three-quarters of the way down the runway and drifting out across the grass to the eastern side of the runway. A second witness, who was a private pilot endorsed on Cessna aircraft, reported seeing some flap but could not remember how much.

A go-around from the attempted landing was commenced as the aircraft neared the end of runway 18. The aircraft continued south beyond the runway, drifting east with the wind and out over the boundary fence at the southern end of the aerodrome. The witnesses feared that the aircraft would not clear a line of trees, approximately 20 metres tall, running approximately east-west beyond the aerodrome boundary. The aircraft then turned to the left while banking sharply and tracked eastwards at very low altitude with its wings rocking and a pronounced nose-high attitude. Its nose then suddenly dropped and it adopted a steep nose-down attitude before impacting the ground. Witnesses attended to the seriously injured occupants while waiting for the local emergency services to arrive. The pilot died in hospital from his injuries.

The owner, who had flown regularly with the pilot, said he was very meticulous with his procedures and that his late decision to go around was out of character. The owner only vaguely remembered the go-around procedure but said he believed that the pilot's actions were standard.

The aircraft came to rest in an open field about 600 metres south of the departure end of runway 18. Ground scars and propeller slash marks showed that the aircraft had impacted in a steep, nose-down, almost wings-level attitude with little forward velocity. It had then bounced about 9 metres to the south-east, where it came to rest. Impact forces severely disrupted the forward section of the fuselage. Post-accident inspection of the airframe indicated that it was intact when it struck the ground.

Approximately 25 litres of clean avgas was drained from each fuel tank 2 days after the accident. Tests revealed no indication of fuel contamination. The weight and balance of the aircraft was calculated to be within limits for landing at Shepparton.

No defects or deficiencies were identified with the aircraft engine or the aircraft's systems that may have compromised its performance or contributed to the accident. The flaps were in the fully retracted position when the aircraft struck the ground and this was verified by the position of the flap position actuator. Damage to the propeller and the ground slash marks made by the propeller at the impact point indicated that the engine was under power at the time of impact. Several witnesses described the engine sound as being normal for an engine at high power.

The Bureau of Meteorology had installed an Automatic Weather Station (AWS) at Shepparton aerodrome. The AWS provided 1-minute averaged data for wind direction and speed and automatically recorded the data for future reference. At the time of the accident the surface wind, as measured by the AWS, was 310 degrees at 9 knots, with a maximum gust within the previous 10 minutes of 20 knots. An experienced private pilot who was flying his aircraft in the Shepparton circuit area at the time of the accident described the wind as a moderate westerly of approximately 15 knots. He noted that he experienced a combination of both mechanical and thermal turbulence, particularly at low level.

With the wind from the west and a turn to the east from a runway heading of 180 degrees, the aircraft will drift downwind while turning. This can create visual illusions that may result in mishandling of the flight controls which, combined with turbulence and wind gusts, may result in height loss, particularly if the aircraft is operating at a high angle of attack.

Aircraft Details
Manufacturer
Cessna Aircraft Company
Model
172
Registration
VH-SXK
Serial number
17267571
Operation type
Private
Sector
Piston
Departure point
Narromine, NSW
Destination
Shepparton, VIC
Damage
Destroyed