Coronial
QLDother

Beresford, Samuel John

Deceased

Samuel John Beresford

Demographics

21y, male

Date of death

2011-03-17

Finding date

2013-12-05

Cause of death

severe head and upper body injuries, due to, or as a consequence of being struck by the propeller blades of a gyroplane

AI-generated summary

Samuel John Beresford, a 21-year-old, died on 17 March 2011 after being struck by propeller blades of a gyroplane on 9 March 2011. He attempted to start the unregistered gyroplane from outside the cockpit at his parents' property. The engine went to high revolutions, the aircraft moved forward uncontrollably, and the propeller struck his head and upper body. Key contributing factors included: inadequate pre-flight inspection after road transport, engine starting at high RPM (cause uncertain—possibly faulty throttle system or magneto switches), lack of aircraft securing measures (no chocks, brakes, or tethering), unregistered gyroplane, absent pilot certification, and deficient flight instruction from the seller Campbell Taylor who did not maintain proper records, did not follow formal training syllabi, and was himself not current. The coroner found no evidence the aircraft was in inherently unsafe condition, though magneto switches may have been intermittent due to age or transport vibration. Clinical/mechanical lessons: proper pre-flight procedures and aircraft security are critical; unregistered, unserviced aircraft and inadequately trained instructors pose serious risks.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Error types

proceduralsystem

Procedures

aircraft engine start procedure

Contributing factors

  • Engine started at high revolutions, cause uncertain
  • Aircraft not adequately chocked or secured
  • Aircraft had no brakes installed
  • Aircraft not tethered to a fixed object
  • Magneto switches may have been faulty or intermittent
  • Inadequate pre-flight inspection after road transport
  • No pilot certificate held
  • Gyroplane unregistered
  • Inadequate and inadequately documented flight instruction from seller
  • Throttle control issue—unclear if mechanical defect or pilot error
  • Pilot attempted to start engine from outside cockpit rather than in-seat

Coroner's recommendations

  1. QPS should consider providing secure vehicle holding-yard facilities in the Cunnamulla area
  2. Sergeant Relf should be permitted to undertake ATSB aviation accident investigation training course at next available vacancy
  3. QPS should identify and ensure a trained pool of officers to specialise in aviation accident investigations with initial advisory and primary investigator roles
  4. QPS should review section 8.5.12 of OPM to remove ambiguity regarding aircraft release procedures when ATSB not investigating
  5. WHSQ should review procedures to ensure relevant agencies are notified of investigation outcomes at conclusion
  6. WHSQ should ensure machinery is not released without coroner's permission where investigation relates to reportable death
  7. CASA should review expectations of ASRA given limited resources and consider increasing ASRA funding or taking back responsibilities
  8. Federal Government should ensure CASA is funded to increase ASRA funding without decreasing funding to other RAAOs
  9. ASRA and CASA should determine how best to regulate aerial stock mustering by gyroplane and simplify registration process
  10. CASA should contact students trained by Campbell Taylor to ascertain training level and quality
  11. CASA should audit current flight instructors to confirm currency and check record keeping
  12. ASRA should not allow Campbell Taylor to obtain gyroplane flight instructor rating in future
  13. ASRA should review accident investigation methodology and ensure proper records kept during inspections
  14. ASRA should include in safety messages and training that unless operationally necessary, pilots must be seated in cockpit when starting gyroplane
  15. ASRA should introduce section in Operations Manual dealing with sale and transfer of gyroplanes with requirements for sellers to provide airframe hours, engine TBO, engine hours, and all manuals
  16. ASRA should require homebuilders and manufacturers to produce Manufacturer's/Owner's Manual with safety, maintenance and servicing guidance
  17. ASRA should consider evidence of transport-related problems and include recommendations in manual
  18. ASRA should draft and implement Technical Manual with specific maintenance guidance and consider mandating appropriate brakes
  19. ASRA should highlight different carburettor configurations and throttle cable actions in Technical Manual
  20. ASRA should consider mandating safety inspections by Technical Advisors at defined periods
  21. ASRA should ensure registration system alerts when flight instructors fail to maintain currency and status visible on website
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