ASN Wikibase Occurrence # 179374
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| Date: | Tuesday 8 September 2015 |
| Time: | 14:10 |
| Type: |  Cessna 172S Skyhawk SP |
| Owner/operator: | Royal Melbourne Institute of Technology |
| Registration: | VH-ZEW |
| MSN: | 172S11079 |
| Fatalities: | Fatalities: 1 / Occupants: 1 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | Millbrook, VIC -
 Australia
|
| Phase: | En route |
| Nature: | Training |
| Departure airport: | Point Cook Airfield (YMPC) |
| Point Cook Airfield (YMPC) | |
| Investigating agency: | ATSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
The Cessna 172S Skyhawk SP crashed into the side of Black Hill and slide for approximately 100 metres, killing the pilot who was the only person onboard.
AAIB report:
What happened
At about 1410 Eastern Standard Time on 8 September 2015, the pilot of a Cessna Aircraft Company 172S, registered VH-ZEW, departed Point Cook Airfield, Victoria, on a solo navigational training flight via waypoints that included Ballarat Airport, Victoria. GPS data showed that the aircraft was on the third leg of the planned journey, cruising at about 3,000 ft above mean sea level when it started to descend rapidly. The aircraft impacted rising terrain at about 2,200 ft and was destroyed. The pilot who was the sole occupant, was fatally injured.
What the ATSB found
The site and wreckage inspection identified that the aircraft impacted terrain in a level, slight right‑wing low attitude. That indicated that the pilot likely stopped the aircraft’s descent and started to initiate a manoeuvre to avoid the terrain. It is likely that the pilot manually manipulated the controls while the autopilot was on and engaged in a vertical mode. As a consequence, the autopilot re-trimmed the aircraft against pilot inputs, inducing a nose-down mistrim situation, which led to a rapid descent. The aircraft’s low operating height above the ground, due to the extent and base of the cloud, along with rising terrain in front of the aircraft, gave the pilot limited time to diagnose, react, and recover before the ground impact.
There was no advice, limitation, or warning in the aircraft pilot operating handbook or avionics manual to indicate that if a force is applied to control column while the autopilot is engaged, that the aircraft’s autopilot system will trim against the control column force, and possibly lead to a significant out of trim situation. Training requirements for autopilot systems was rudimentary at the recreational pilot licence (RPL) level due to stipulated operational limitations for its use. At the time of the accident there was no regulatory requirement for pilots to demonstrate autopilot competency at the RPL level.
What's been done as a result
The ATSB issued safety recommendations to the aircraft and autopilot manufacturers about the provision of limitations, cautions and warnings for autopilot systems and audible pitch trim movement.
The flight training organisation updated their operations manual, as a result of flight testing they conducted, to include warnings about the operation and function of the autopilot system absent in the manufacturer’s documentation. The hazard of manual manipulation of the flight controls with the autopilot engaged was also emphasised to students.
Safety message
Technologically advanced avionics and autopilot systems are now often fitted to general aviation aircraft used for flight training, private and charter operations. It is essential for all pilots to develop a thorough understanding and operation of all systems fitted to the aircraft they are flying. It is also important that student pilots consolidate manual flight and navigation skills before using the advanced auto flight modes or extensively using autopilot systems. Avionics and aircraft manufacturers should increase pilot awareness of automated systems by providing written warnings surrounding known issues and including visual and aural alerts in auto flight systems to increase pilot awareness of non-standard inputs. Fundamentally, pilots should be aware that if the automation is not performing as expected, then the safest option under most circumstances is to disengage the system and manually fly the aircraft.
__________
The ATSB is highlighting the consequences of pilots not fully understanding how their aircraft’s avionics and autopilot systems operate.
The investigation into the fatal accident of a Cessna 172S has resulted in the Bureau issuing safety recommendations to the aircraft and autopilot manufacturers about providing limitations, cautions and warnings for autopilot systems and audible pitch trim movement.
The accident occurred on 8 September 2015, when a Cessna 172S was conducting a solo navigation training flight from Point Cook Airfield in Victoria. GPS data later showed the aircraft was on the third leg of the planned journey, cruising at about 3,000 ft above mean sea level, when it started to descend rapidly. The aircraft impacted rising terrain at about 2,200 ft and was destroyed. The pilot, who was the sole occupant, was fatally injured.
The investigation found that it was likely the pilot had manually manipulated the controls while the autopilot was on and engaged in a vertical mode. As a consequence, the autopilot re-trimmed the aircraft against pilot inputs, inducing a nose-down mistrim situation, which led to a rapid descent. The aircraft’s low operating height above the ground, along with rising terrain in front of the aircraft, would have given the pilot limited time to diagnose, react, and recover before impact. The investigation indicates that the pilot may have been unaware of the exact properties of the autopilot.
ATSB Executive Director, Mr Nat Nagy, said that this accident highlighted a matter of serious concern.
“It is now common for general aviation aircraft to be equipped with advanced avionics and autopilot systems,” Mr Nagy said. “And while these systems can be very useful, it is vitally important that pilots understand how the systems will react in different circumstances.”
After the accident, the flight training organisation conducted flight testing and has emphasised to their students the hazard of manually manipulating the flight controls with the autopilot engaged. They have also updated their operations manual to include warnings about the operation and function of the autopilot system - warnings that are absent in the manufacturer’s documentation.
“This is knowledge that all pilots need to possess,” Mr Nagy said. “Pilots should also be aware that if automation is not performing as expected, then the safest option under most circumstances is for them to disengage the system and fly the aircraft manually.”
The ATSB issued recommendations to the aircraft and autopilot manufacturers, calling for them to provide limitation, cautions, and warnings for autopilots and audible pitch trim movement.
Accident investigation:
 |
|
Sources:
https://www.atsb.gov.au/publications/investigation_reports/2015/aair/ao-2015-105.aspx
https://flightaware.com/live/flight/VHZEW
http://www.theage.com.au/victoria/one-dead-in-light-plane-crash-at-millbrook-20150908-gjhu74.html
http://www.abc.net.au/news/2015-09-08/crews-responding-to-reports-of-plane-crash-near-ballarat/6759228
http://www.heraldsun.com.au/news/victoria/plane-crash-at-millbrook-one-dead-after-light-aircraft-crashes-near-ballarat/story-fni0fit3-1227518159496
AAIB:
https://www.atsb.gov.au/publications/investigation_reports/2015/aair/ao-2015-105/
https://www.atsb.gov.au/newsroom/news-items/2018/flying-against-the-autopilot/
Images:
Media:
The ATSB has issued important safety recommendations to aircraft and autopilot manufacturers as a result of an investigation into a fatal aircraft accident.
— ATSB (@atsbinfo) 17 avril 2018
Read more: https://t.co/th5bn8r45W pic.twitter.com/fHDf2jlsVD
Fatal crash of light plane into the side of a hill at Millbrook @7NewsMelbourne pic.twitter.com/cNISlcadjh
— Phil Loschiavo (@LoschiavoPhil7) September 8, 2015Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 08-Sep-2015 08:22 | bidgee | Added |
| 08-Sep-2015 08:23 | harro | Updated [Embed code] |
| 16-Oct-2015 06:05 | Anon. | Updated [Time, Nature, Source, Embed code] |
| 17-Apr-2018 05:43 | Iceman 29 | Updated [Other fatalities, Phase, Departure airport, Destination airport, Source, Embed code, Narrative, Photo, ] |
| 06-May-2018 13:49 | harro | Updated [Embed code] |
| 17-Jul-2019 19:13 | RobertMB | Updated [Aircraft type, Narrative] |
| 09-Jun-2022 20:48 | Ron Averes | Updated [Location] |
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