Occurrence
On the afternoon of 16 June 2023, a Cessna 210L, registered VH-FTM and operated by Katherine Aviation, departed from runway 10 at Groote Eylandt Airport, Northern Territory, with a pilot and five passengers on board. Shortly after becoming airborne at an altitude of about 100 ft, the pilot reported engine surging accompanied by fuel flow fluctuations. During an attempted turn back and landing, the aircraft passed diagonally over the runway and touched down in a clear grassed area outside the airport boundary. It continued along the ground for approximately 120 m and struck an embankment, causing the aircraft to flip and come to rest inverted on a service road. Three passengers sustained serious injuries, while the pilot and two passengers received minor injuries. The aircraft was substantially damaged.
Investigation Findings
The Australian Transport Safety Bureau (ATSB) determined that the engine mixture control was probably not set to full rich prior to the take-off, resulting in reduced power and unanticipated engine behaviour. The pilot, likely surprised by the partial power loss and compounded by limited experience in the Cessna 210, took no action to resolve the situation and did not effectively manage the attempted landing. The pilot's take-off safety self-brief and the operator's documented example brief did not include actions for a partial power loss. Additionally, the pilot had not completed weight and balance calculations for the flight, and the aircraft departed 10 kg above the maximum take-off weight. The ATSB also identified that the aircraft was likely operated with a time-expired engine-driven fuel pump, although the pump was unlikely to have contributed to the partial power loss. The aircraft did not have, and was not required to have, upper torso restraints fitted to the rear passenger seats, which increased the likelihood of serious injury in an accident.
Actions Taken
On 17 June 2023, the Civil Aviation Safety Authority (CASA) issued a safety alert to Katherine Aviation requiring a fleet-wide check of all time-lifed components fitted or about to be fitted to the aircraft, following the identification of the time-expired engine-driven fuel pump on VH-FTM. On 22 June 2023, Katherine Aviation completed the check and identified several additional defects. In response, the organization agreed to implement a maintenance incident reporting system and discontinue the cross-hire of aircraft to reduce engineering workload.