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Last updated: 12 July 2020
Status:Final
Date:Saturday 8 December 2018
Time:12:22
Type:Silhouette image of generic BE20 model; specific model in this crash may look slightly different
Beechcraft 200 Super King Air
Operator:Desert-Air Safaris
Registration: VH-ODI
C/n / msn: BB-634
First flight: 1980
Crew:Fatalities: 0 / Occupants: 1
Passengers:Fatalities: 0 / Occupants: 7
Total:Fatalities: 0 / Occupants: 8
Aircraft damage: Substantial
Location:Mount Gambier Airport, SA (MGB) (   Australia)
Phase: Landing (LDG)
Nature:Unknown
Departure airport:Adelaide Airport, SA (ADL/YPAD), Australia
Destination airport:Mount Gambier Airport, SA (MGB/YMTG), Australia
Narrative:
The pilot of a Desert-Air Safaris Beech B200, registered VH-ODI (ODI), prepared to conduct a charter flight from Adelaide, Australia to Mount Gambier with seven passengers on board. One of the passengers occupied the right flight deck seat as an observer. This observer held a commercial pilot licence, but was not a member of the flight crew
At 11:09, the flight departed Adelaide Airport. During the flight, the pilot received a Special Weather Report (SPECI), stating overcast cloud at 512 ft AMSL, below the approach minimum descent altitude (MDA) of 730 ft AMSL. The SPECI also reported visibility greater than 10 km and a southerly wind of 11 kt.
At 12:00, ODI commenced the Runway 18 RNAV approach behind a preceding aircraft. As the preceding aircraft continued the approach, the flight crew of that aircraft received an alert indicating the loss of the GNSS receiver autonomous integrity monitoring (RAIM) and conducted a go-around.
Despite not receiving a similar alert, the pilot of ODI also elected to conduct a go-around. He climbed the aircraft to an altitude of 5,000 feet and proceeded with the missed approach procedure to waypoint MTGNE to commence another approach. The other aircraft then advised that they would hold at waypoint MTGND while ODI conducted another approach.
At 12:15, ODI commenced a second approach to Runway 18 from waypoint MTGNE.
During the flight and approaches, the observer contributed to the operation of the aircraft, a.o. by calling out operational checklists and monitoring the approach and calling out excursions from the target altitude.
The approach chart indicated that a normal descent profile should position the aircraft at 980 ft, 2 NM prior to the missed approach point at MTGNM. As the aircraft crossed this point, the pilot announced that the aircraft was 'too fast by far' and 'high'.
On multiple occasions throughout the approach, the pilot questioned and corrected information provided by the observer and educated her on the operation of the flight.
As the aircraft descended to 730ft, the observer announced that they had reached the MDA. Upon reaching the MDA, the pilot could see the ground directly beneath the aircraft, but could not see the runway ahead. He then announced that he would conduct a go-around and retracted the landing gear, without announcing that he had done so. The observer was unaware that the landing gear had been retracted. After the pilot announced the go-around, the engine power level did not increase.
Nine seconds after the landing gear was retracted, the pilot and observer sighted the runway. The pilot then reduced power and selected full flap to continue the approach. He noted that the required approach profile from that position was 'very steep'.
At that time, the landing gear warning tone activated. As the approach continued, the ground proximity warning system (GPWS) 'check gear' aural alert also activated. In response, the pilot incorrectly announced that the landing gear was extended. The approach continued, and 5 seconds later the GPWS alert 'pull up' also activated. The observer announced that the 'pull up' warning had activated. The pilot acknowledged this call, announced 'I've got it' and continued the approach. One second later, the 'pull up' and 'check gear' alerts ceased, but the landing gear warning tone continued (the pilot and observer both later recalled not hearing the landing gear warning tone or GPWS 'check gear' alerts).
At 12:22, the aircraft briefly touched down on the propellers and bounced. Two seconds later, the propellers again contacted the runway. The pilot, believing the landing gear was down and the aircraft had landed on the runway, twice attempted unsuccessfully to engage reverse thrust.
The aircraft continued flying above the runway at low level and began to drift right toward the runway edge. The pilot, believing the aircraft to be rolling on the landing gear and not responding to brake inputs, assessed that it could not be stopped in the remaining runway and elected to conduct a go-around. He then increased engine power and observed good initial response from both engines followed shortly after by failure of the left engine.
The pilot completed the initial engine failure actions and announced 'gear up, flap up' and the landing gear warning tone then ceased operating, consistent with flap retraction. Following the flap retraction, the stall warning activated intermittently for 16 seconds.
The pilot shut down and secured the left engine and assessed that the right engine was performing as expected. He then conducted a visual left circuit at an altitude of about 600-650 ft AMSL, and at 12:24 the aircraft landed on Runway 18 and vacated on to Runway 29 where it was shut down.
The observer assisted with passenger disembarkation onto Runway 29 and escorted them clear of the runway. No persons were injured during the accident however, the aircraft was substantially damaged.

Probable Cause:

Contributing factors:
- The pilot elected to continue the approach after initially deciding to conduct a go-around. The pilot's expectation of the landing gear position, possibly coupled with the effects of the now increased workload, probably led to him not detecting the retracted landing gear before the aircraft contacted the runway.
Other findings
- After the wheels-up landing, the decision to conduct a go-around resulted from the pilot’s misunderstanding of the situation and assessment that a runway overrun was imminent.

Accident investigation:
cover
Investigating agency: ATSB
Status: Investigation completed
Duration: 1 year and 5 months
Accident number: AO-2018-080
Download report: Final report

Classification:
Gear-up landing
Runway mishap

Sources:
» ATSB
» Flightaware flight track

METAR Weather report:
01:00 UTC / 11:30 local time:
YMTG 080100Z AUTO 17011KT 9999 // OVC004 16/15 Q1018

02:00 UTC / 12:30 local time:
YMTG 080200Z AUTO 18012KT 9999 // OVC004 16/15 Q1018


Photos

photo of Beechcraft-200-Super-King-Air-VH-ODI
 

Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Adelaide Airport, SA to Mount Gambier Airport, SA as the crow flies is 370 km (231 miles).

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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