Fatal Hedlow plane crash investigation report leads to claim
THE day a Rockhampton firefighter died during a flying lesson, the instructor had cancelled an earlier lesson because of weather conditions.
It has been three years since Jason Caswell and his instructing pilot John Anthony Creswell of Caboolture died in a crash at Hedlow Airfield.
It was meant to be a flight of celebration as Jason completed his 12th lesson in the ultralight kite on November 25, 2016, when the tragedy occurred.
The Gracemere resident left behind his wife Karen and their two daughters Darci and Madison now aged 10 and 8.
Jason had been involved with Pathfinders, the Seventh-day Adventist Church's youth program that is similar to scouts, since he was 10. He had been in Adventurers, the youth group the church members join before Pathfinders, since he was five.
After being a Pathfinder member, he became a leader, went on to be a director and was the district director for Central Queensland.
Mrs Caswell has been granted permission by the courts to proceed with a civil lawsuit against the company that ran the training program, Rockhampton Sport Aviation (RSA).
RSA operates as a satellite flight training facility for Caboolture Microlights.
Mrs Caswell has also been granted permission to proceed with a lawsuit against the estate of flight instructor Mr Creswell.
Documents filed with the Supreme Court in Rockhampton show the lawsuit is expected to be filed on the grounds of a claim the crash occurred as a result of negligence which also breached a contract and breached statutory guarantees.
The claim is RSA breached the training contract in that Mr Creswell decided to conduct the flight in conditions that were unsuitable due to high air temperature, wind gusts and greater than normal likelihood of turbulence.
It is also claimed the flight ought not have been carried out and instead postponed to another day.
It is further claimed the flight carried out "by a very inexperienced trainee such as the deceased"; and in the prevailing conditions, Mr Creswell should have directed the trainee to conduct an approach at higher speed and altitude commensurate with the conditions and to anticipate the risks of turbulence, rather than a shallow routine approach.
Further, it is claimed Mr Creswell did not give adequate instruction to the trainee to pilot the aircraft to a safe landing, did not implement and maintain any adequate system to assess the risk posed by high air temperatures, wind gusts and/or greater than normal turbulence and did not implement and maintain any adequate system to cease student training operations when these reached a threshold.
The plaintiff claims RSA and Mr Creswell did not supply the training services in conformity with each guarantee by reason of the matters alleged above and downplayed in their promotional material the risks associated with flying and learning to fly an Airborne Edge XT912 aircraft, and further failed to comply with Australian consumer laws.
The accident occurred when the Airborne Edge XT912 microlight aircraft, in which Jason and Mr Creswell were seated in tandem, departed controlled flight and entered a rapid nose-down spiral before striking about 220m west southwest of runway 07 (which faces east) at the airfield.
The accident was investigated by Robert Kells, a former Australian Transport Safety Bureau investigator with over 26 years' experience in air crash investigations and crash investigation training, on behalf of Rockhampton Police.
The aircraft left Hedlow, a privately-owned airstrip about 29km northeast of Rockhampton, about 1.10pm and is believed to have crashed about 2.20pm.
Jason was undergoing training in "unusual attitude recovery" and "touch and go" operations at the time, under instruction of Mr Creswell.
CCTV footage of the event, captured on camera located at a nearby quarry, showed the aircraft on what appeared to be a normal descent profile to land before suddenly departing controlled flight in a nose-down and clockwise spiral before striking the ground about 220m from the runway. This took only four seconds and Mr Kells noted that recovery was unlikely from the height where control was lost.
The ground mark evidence showed that when the aircraft impacted the terrain, it was still rotating to the right, slightly nose-down, in a near-vertical descent and with relatively little forward (horizontal) energy. The CCTV shows the trike completed 1.25 to 1.5 turns before impact. Mr Kells noted that was consistent with the direction the fuselage (central body of the aeroplane) came to rest.
The accident site was about 100m beyond the tree-lined Hedlow creek.
The terrain surrounding the accident site was cleared open paddock and dry hard soil.
The evidence showed the aircraft impacted the terrain slightly nose-down and heavily on the right side.
The evidence showed that the aircraft bounced on impact and travelled rearward about 2-3m from the initial impact site before coming to rest under the one-piece wing.
During the impact sequence, the aircraft's wing separated from the fuselage and rolled inverted before coming to rest diagonally across and on top of fuselage.
Propeller debris plus several pieces of lighter wreckage were found in a large arc outside the main wreckage.
All blades were broken and separated about mid span and the outboard section of each had thrown outward. The inboard section of each blade had also broken and separated at the propeller hub attachment.
The inboard section of all three blades exhibited a similar degree of cracking along the lower portion of the leading and trailing edges, where each blade separated from the hub.
Several pieces of lighter wreckage, including the student pilot's helmet, were found several metres from the main impact site.
In the analysis of the report, Mr Kells stated that in considering the possibility of an in-flight structural failure due to possible thermal activity, two things needed to be known - the speed the aircraft was travelling at and the possibility of strong turbulent or gusting winds.
Due to the manner in which the CCTV footage is recorded and also considering the aircraft may have been crossing the CCTV camera at an oblique angle, the investigation was not able to confirm the speed of the aircraft.
The weather in the area at the time was variously reported to include light to moderate southeast to northeast winds, little cloud below 1500m and moderate turbulence possible in thermals. If the wind was not greater than that indicated by the forecast and also as indicated by several pilot witnesses, it is considered unlikely by itself to have been severe enough to cause an in-flight structural failure.
The indications for the manner and speed with which the aircraft initially departed normal flight and descended nose-down, is similar in many ways to what would be expected for either an in-flight structural failure or a significant control upset.
If the right outer right wing-tip did fail in flight ... it would be reasonable to expect the entire right-wing structure generally would exhibit more severe bending and compression type damage than the left wing.
Examination of the wreckage found no evidence of pre-existing damage or mechanical fault that may have contributed to the development of the accident.
The aircraft's maintenance logbook shows that the last scheduled 100 hourly maintenance inspection took place at 275 hours and four minutes on September 20, 2016.
Post-mortem reports showed there were no physiological issues with either crew member. Jason sustained non-survivable injuries to his skull, brain and aorta. Mr Creswell sustained non-survivable injuries to his heart and aorta.
It is therefore possible that a wind gust, or a combination of thermal updrafts and mechanical turbulence, possibly due to the location of the trees near the creek, was the most probable initiating event.
Mechanical turbulence at low altitudes is created by obstacles such as buildings, trees and hills. The normal horizontal wind flow is disturbed and transformed into a complicated pattern of irregular air movement, forming swirls and whirlpools. Mechanical turbulence usually becomes more severe in stronger winds and can be a significant hazard during approach and landing. The combination of a tree-lined creek west of the runway, ground temperature and wind may have produced mechanical turbulence.
The witness estimates of the wind and gust speeds varied significantly, some were higher and some lower than the forecast winds for both Rockhampton and Yeppoon. In considering all of the forecast and estimated wind conditions, it is possible that the conditions at Hedlow would have been marginal for conducting training exercises in this aircraft type.
The investigation was not able to identify conclusively the cause for the initial control upset. However, the likelihood that wind turbulence or a gusting upset was one of the initiating factors could not be discounted.
Mr Kells stated a loss of engine power is not an event which would usually lead to a rapid loss of control. It would normally lead to a glide approach either to the accident site or to a cleared area.
This was especially so in a case where the cleared area before the airstrip and even possibly the runway itself is within gliding distance.
Jason's student pilot log book showed he had 22 hours 25 minutes' aeronautical experience with 17.1 hours on weight shift aircraft (WSC) prior to the accident. All of his WSC time was logged on the XT912 Arrow wing trike.
He had a further four hours and 45 minutes flight time on three-axis aircraft types.
Scott Frame, firefighter, stated he 'watched the aircraft taxi for three minutes to the runway at 12.57pm, taking off 10 minutes later after going through standard preflight checks' - indicated estimate departure time of 1.10pm.
Mr Frame stated he noticed the microlight did not have a smooth ascent, dipping several times, likely due to wind gusts.
He stated the winds were gusty, changing from east to northeast at about 30-35km/h.
Robert Woodward, firefighter, stated at about 3.15pm an aircraft was returning to Rockhampton and the pilot radioed that an aircraft had crashed at the end of the runway.
Howard Veal, who has more than 40 years' flying experience, stated on the day of the crash he was flying a Cessna 337 with call sign "Birdog 410" for the Rural Fire Service. He was returning from Gladstone about 2pm, landing on the runway and shut his aircraft down at 2.04pm. He further stated that on the final approach to the runway, the wind was noted at about 80 degrees east northeast and about 18.5km/h.
Rodney Ginn, a commercial pilot with 22 years' experience, was on standby for fire spotting on the day. He stated it was a hot day in the mid-30s and wind was a little gusty.
Rohan Lloyd, a commercial pilot with 31 years' experience, was on fire suppression standby nearby. He stated that about 10.30am, a couple of people from the microlight school dragged a trike out of the hangar. At the time, the weather conditions included six parts of eight were covered in cloudat 90m, wind 28-37km/h at 140 degrees, gusting.
Mr Lloyd further stated he thought the conditions would not be good for a microlight to fly in.
Steve Bartlett stated Bureau of Meteorology observation report for the day showed easterly winds at 17km/h in the morning and easterly in the afternoon 15km/h - suiting the runway. He further stated highest wind gust 31km/h, well within the aircraft and pilot in command Mr Creswell's capabilities.
Myles James stated he collected Mr Creswell from Mr Bartlett's house early and they drove to Hedlow airfield. Mr James conducted a solo flight under Mr Creswell's supervision and on his return, Jason had arrived. Mr James stated Jason conducted a 0.5hr check flight with Mr Creswell before he conducted a 0.5hrs solo circuit exercise. On Jason's return, Mr James was to conduct another one hour solo flight. It was decided a solo flight was not suitable due to Mr Creswell's assessment of the weather. Mr James helped Jason prep and fuel (35 litre) the trike for storage before returning to Rockhampton for work about 10am.
Microlight crashes in Australia are not investigated by the Australian Transport Safety Bureau because of the aircraft's registration status. The crashes are investigated by individual state police, Recreational Aviation Australia (RAAus) or the Hang Gliding Federation of Australia (HGFA). There is no central database linking microlight crashes. As a result, it is hard to establish any possible similarities or connection between weight shift trike accidents or incidents.
No electronic data was retrievable from the aircraft post-crash. The fitting of video cameras to aircraft would assist with air crash investigation, training and future development within the microlight industry.
RAAus and HGFA develop a reporting system linking all crashes to distribute the results of safety investigation findings and recommendations, particularly in regards to likely weather-related control and handling issues.
RAAus and HGFA in conjunction with the manufacturers continue to update and circulate safety publications addressing training and handling issues.
The manufacturer (Airborne Australia), RAAus and HGFA be given permission to view wreckage and evidence under observation of police, to value add to information already obtained. This may assist with further development into aircraft and future air crash investigations.