Originally Posted by The ATSB

History of the flight

On 14 October 2014, at 1321 Eastern Daylight-saving time,[1] the pilot of an amateur‑built Van?s RV-6A aircraft, registered VH-JON and being operated in the ?Experimental Category?, reported taxiing for a local flight at Moorabbin Airport, Victoria. The aircraft was subsequently cleared by air traffic control for take-off from runway 17 Right at 1323 and to maintain runway heading to depart the control zone to the south. The aircraft was then observed on Airservices Australia surveillance radar climbing to 2,900 ft above mean sea level (AMSL) and tracking southbound via the coast, in accordance with the published departure procedures for Moorabbin Airport. After 1326:07 no further radar returns were received from the aircraft.

The aircraft was observed by witnesses descending rapidly before impacting the ground next to a house in the suburb of Chelsea, 8 km to the south of Moorabbin. The aircraft was destroyed by the impact and the pilot was fatally injured.

There were a number of small post-impact fires started by the accident that were subsequently extinguished by members of the public and the fire brigade. A number of houses and several cars also sustained significant damage as a result of the accident.

Pilot information

The pilot held commercial and private flight crew licences with an aeroplane category rating. The licences were endorsed with single- and multi-engine class ratings and design feature endorsements for manual propeller-pitch-control and retractable undercarriage. The licences were also endorsed with instrument flight with 3-dimensional and 2-dimensional instrument approach privileges and night visual flight operational ratings. Both ratings were restricted to single-engine aircraft.

The pilot held a current class 2 medical certificate, which meant that the pilot could only exercise the privileges of a private pilot licence. The certificate included restrictions that distance vision correction was to be worn by the pilot and reading vision correction was to be available while exercising the privileges of the licence. The pilot last underwent an aviation medical examination 12 days prior to the accident. During that examination the pilot reported a total of 1,659 flying hours, with 17 hours flown in the last 6 months.

It was reported that the pilot appeared to be well rested in the 72 hours prior to the accident. No medical or other issues were reported to family members by the pilot in that period.

Aircraft information

Civil Aviation Safety Authority records indicated that the aircraft was constructed in 1999. It was first registered as an amateur-built aircraft in 2003 by the pilot, who was also the registered owner and operator.

A search of the Australian Transport Safety Bureau (ATSB) occurrence database revealed that the aircraft was involved in two previous accidents. In 2007, the aircraft sustained an engine failure and damage during the resultant forced landing. The Honda V6 engine that was installed at the time was reportedly removed and a new Lycoming IO‑360 aircraft engine installed in its place. It was also reported that the damage was repaired and the aircraft returned to flying status.

The aircraft was again damaged during a landing accident in 2010 when the nose wheel collapsed and the propeller contacted the ground while the engine was running. The engine was reportedly replaced with another Lycoming IO‑360 engine, the damage repaired and the aircraft returned to flying status.

The aircraft was also reported to have been involved in an incident approximately 1 month prior to this October 2014 accident, when an engine fire occurred whilst the aircraft was taxiing at Moorabbin. The fire was extinguished with the assistance of other persons. It was reported that the engine and associated areas of the aircraft were inspected by the pilot, who reported to friends that there appeared to be no damage as a result of the fire.

Aircraft refuelling

None of the mobile refuelling agencies at Moorabbin reported supplying fuel to the aircraft on the day of the accident.

The Dynon EMS-D120 engine monitoring system fitted to the aircraft recorded data relating to the total amount of fuel on board (see the section titled Onboard recording devices). The last system-recorded date of an increase in the amount of fuel on board coincided with the last recorded date that the pilot purchased fuel (AVGAS 100 low-lead) from a self‑service bowser at Moorabbin.

The EMS-D120 data showed that the aircraft completed three separate flights over a period of about a month after that refuelling, totalling 2.1 hours. This did not include the accident flight.

Weather information

The weather conditions at the time were reported to include a moderate to strong southerly wind at 17 kt, with some mid-level cloud in the area. Visibility was reported to be greater than 10 km. These conditions were consistent with the forecasts for Moorabbin and the greater Melbourne area.

Communications

Examination of the recorded air traffic control radio transmissions for Moorabbin Tower and the associated flight information service frequency to the south of Moorabbin revealed no emergency broadcast from the pilot. There was no evidence of any partial transmissions, open‑microphone transmissions[2] or over-transmissions[3] during the flight.

Aircraft wreckage information

Wreckage examination

The aircraft impacted a house fence and adjoining laneway in a significant nose-down attitude at high speed. The initial impact was to the left wing, which indicated a left wing‑down attitude of about 10? at the time. Witness marks on the fence indicated a descent angle of about 35?.

The aircraft commenced breaking up after the initial impact, with the left wing remaining at the initial impact point and the remainder of the aircraft continuing along the laneway. The propeller and engine separated from the fuselage and came to rest approximately 48 m and 68 m respectively from the point of impact.

The vertical and horizontal tail surfaces also separated from the fuselage and from each other and were located along the wreckage trail. The right wing and remainder of the fuselage came to rest approximately 95 m from the impact point but remained largely intact.

The remainder of the aircraft, including the cockpit, was destroyed during the impact sequence. Items associated with the aircraft were located in the laneway up to 130 m from the point of impact.

All flight controls and major aircraft components, including the cockpit canopy, were identified at the accident site.

Examination of the fuselage revealed considerable oil coating on the external surfaces. Oil was also found on the upper surface of the right wing and right horizontal stabiliser (Figure 1). There was very little oil coating on the left horizontal stabiliser and none on the left wing. Examination of recovered fragments of the cockpit canopy also showed oil coating on their internal and external surfaces.

Figure 1: Horizontal stabilisers displaying right stabiliser oil coating

Source: ATSB

The engine and propeller were recovered for later technical examination under the supervision of the ATSB.

Originally Posted by The ATSB

Recovered items

A number of aviation-related items were reported recovered at distances of up to 3 km from the accident site by members of the public and handed in to Victoria Police (Figure 2). These items included the pilot?s flight crew licence and aviation medical certificate, an aircraft pitot cover and warning flag, a flight bag, an En Route Supplement Australia (ERSA)[4] and a very high frequency (VHF) handheld transceiver and antenna.

Figure 2: Location of recovered aviation-related items relative to the accident site

Source: ATSB

Recorded information

Onboard recording devices

A number of electronic devices were recovered from the aircraft wreckage with the capability to record in-flight data. These included two Garmin global positioning system (GPS) units, a Dynon EFIS-D100 electronic flight information system and a Dynon EMS‑D120 engine monitoring system.

GPS units

Initial examination of the GPS units revealed significant damage. Further detailed examination is required to establish if any data can be recovered from either GPS.

EFIS-D100

Examination of the EFIS-D100 unit revealed that it was not configured for data logging. No relevant data was recovered from this unit.

EMS-D120

The EMS-D120 unit logged data from the accident flight. This included the aircraft?s GPS ground track and derived ground speed (Figure 3). When compared to the recorded radar data, the GPS ground track was consistent with the aircraft?s recorded radar track. No altitude or airspeed information was logged by the unit.

A number of engine operating parameters were also recorded by the EMS-D120.These parameters revealed that the engine appeared to be performing normally during the take‑off, climb to altitude and short cruise period. Work is ongoing to explain a decrease in the engine oil pressure about 7 seconds before the end of the recorded data.

The last valid data logged was time stamped at 1326:00.[5] The corresponding GPS position showed the aircraft approximately 640 m to the north of the accident site at that time.

Figure 3: Recovered data from the EMS-D120

Source: ATSB

Closed-circuit television footage

Closed-circuit television (CCTV) footage of the aircraft as it taxied at Moorabbin that day revealed no apparent anomalies with the aircraft. The aircraft?s cockpit canopy was in the lowered position at that time.

Other CCTV security cameras at Chelsea captured the last seconds of the flight. Analysis of that footage confirmed a steep nose-down flight path and an aircraft speed of approximately 200 kt (370 km/hr) leading up to the impact with terrain.

Radar data

Examination of the recorded radar data showed the aircraft climbing out of Moorabbin on runway heading at 1323:53. Twenty-eight valid radar returns were recorded for the aircraft, which was transmitting radar transponder code 3000.[6] The last valid return was at 1326:07 and indicated an altitude of 2,500 ft. Other traffic in the vicinity was detected by radar at altitudes as low as 1,100 ft.

Further investigation

The investigation is continuing and will include examination of the:
?engine and propeller
?cockpit canopy locking mechanisms in a number of similar aircraft
?construction, maintenance and repair history of the aircraft
?viability of recovering additional data from the accident‑damaged GPS units
?radar data from a number of additional radar heads to determine if any further returns were recorded from the aircraft
?pilot?s medical and flying history.

Originally Posted by aarvig (Post 939151)

Wow, both the Canadian and Australian accident reporting authorities put out very through reports. Especially relative to the NTSB. I wonder why that is?
My thoughts and prayers to all involved in this crash.

Originally Posted by aarvig (Post 939151)

Wow, both the Canadian and Australian accident reporting authorities put out very through reports. Especially relative to the NTSB. I wonder why that is?

Originally Posted by Kevin Horton (Post 939325)

I can?t speak to Australia, but I know that in Canada the TSB does not do much of an investigation for most private general aviation accidents. There isn?t much new to learn from most accidents, so a full investigation isn?t a good use of their limited resources. But, if they see an accident that looks like there might be something new to learn, they do a proper investigation.