On 30 November 2022, at 1315 Pacific Standard Time (2115 Coordinated Universal Time), an Arion Lightning aircraft, registered N60MY, departed controlled flight on approach to Zamperini Field (California, United States), and collided with terrain short of the runway. The two occupants were fatally injured.
The United States National Transportation Safety Board (NTSB) investigated this occurrence. As Australia was the State of Manufacture of the aircraft's engine (Jabiru 3300), the NTSB requested appointment of an Accredited Representative from the ATSB. To facilitate this request, the ATSB as the Accredited Representative initiated an external investigation under the provisions of the Transport Safety Investigation Act 2003.
On 5 December 2024, the NTSB released the final investigation report into this accident. Accordingly, the ATSB has concluded its involvement in the investigation. A copy of the report can be requested from the NTSB at https://www.ntsb.gov. Any enquiries relating to the investigation should be directed to the NTSB.
Occurrence summary
Investigation number
AA-2022-002
Occurrence date
30/11/2022
Location
near Zamperini Field Airport, California, United States
On 17 November 2022, the flight crew of a Beech 1900D aircraft, registered VH-NYA, refuelled then boarded passengers at Fortnum Aerodrome for a flight to Perth, Western Australia. On the gravel-surface apron, there were pieces of conveyor-belt matting fixed to the ground to allow engines to be operated with minimal propeller damage.
The crew started both engines and taxied the aircraft to an adjacent parking area to allow another aircraft to access the refuelling truck. The crew positioned the aircraft propellers over the matting to complete pre-flight checklists. On completion of the checklists, the crew applied engine power to taxi to the runway.
Immediately there was a loud bang and severe vibration. The captain observed that the left propeller was damaged and shutdown the engines. The passengers were disembarked and escorted of the apron. There were no injuries.
What the ATSB found
As the flight crew was conducting pre-take-off checks, the end of conveyer belt matting under the left propeller was drawn into the propeller arc, resulting in a sheared propeller blade and vibration damage to the aircraft.
The conveyer belt matting installed on the aerodrome apron was a non-standard method to prevent propeller damage and was not subject to any installation specifications or inspection requirements.
What has been done as a result
The aircraft operator requested that the aerodrome operator remove the conveyor belt strips from the aerodrome apron, which was carried out.
Safety message
As this occurrence demonstrates, the consequences of a propeller strike can be serious, and operators of aircraft and aerodromes are advised to review the use of any non-standard surfaces for aircraft movement areas.
Fortnum Aerodrome has a gravel runway, taxiways, and parking area. In the parking area, there were designated parking areas with pieces of conveyor-belt matting fixed to the ground to allow engines to be operated with minimal propeller damage from loose gravel.
VH-NYA was the first to arrive at Fortnum and the flight crew parked the aircraft near the fuel truck to allow refuelling. After refuelling and boarding the passengers, the crew started both engines and taxied the aircraft to one of the designated parking areas to allow a following aircraft to access the fuel truck.
The crew positioned the aircraft propellers over the matting to complete pre-flight checklists. This was in accordance with operator instructions to prevent stone damage to the propeller blades. On completion of the checklists, the crew applied engine power to taxi to the runway.
Immediately there was a loud bang and severe vibration. The captain observed that the left propeller was damaged and shutdown the engines. The passengers were disembarked and escorted off the apron. There were no injuries.
The aerodrome manager, who witnessed the event, advised that the propeller picked up a corner of the matting and one propeller blade was ejected about 50-100 m in the air. The blade landed on the apron about 10 m in front of the other aircraft parked near the fuel truck.
Figure 1: Damaged aircraft and dislodged matting
Source: Westgold Resources Ltd (cropped by the ATSB)
Fortnum Aerodrome was operated by Westgold Resources Limited in support of their nearby gold mining operation. The aerodrome had been renovated in 2019 under the supervision of an aerodrome consultant. Although the aerodrome was uncertified, the operator had processes for daily and weekly aerodrome inspections by trained aerodrome reporting officers (AROs).
On the morning of 17 November 2022, the ARO conducted a daily inspection of the aerodrome and completed the associated checklist form. All of the apron (parking and movement area) items were annotated as meeting the standard.
The daily apron assessment items included, ‘no loose material or debris on apron or flanks’ but did not include reference to the mats. There was also no reference to the mats in the weekly inspection checklist.
The mats had been installed by the aerodrome operator about 3 years previously in response to a request from the aircraft operator. There was no record of any technical consideration of mat security. The matting involved in this occurrence was in 3 sections and held down by large nails between 200–250 mm length. The outer belt was newer than the inner belt and its end was nailed down at the corners and the middle (Figure 2). The end of the inner belt had been nailed only at the corners. A white line had been applied to the centre of the matting, which was used by the crew to position to the aircraft.
According to the aerodrome operator, there was no record of any communication between the aircraft operator and the aerodrome operator about the condition of the mats. The aerodrome manager recalled that on one occasion a mat was dislodged by twisting associated with aircraft wheel movement. The captain of VH-NYA advised that previously mats had been reported coming loose and these had been resecured.
The aerodrome operator engaged the aerodrome consultant to conduct annual aerodrome audits. In the audit prior to the occurrence, on 11 February 2022, the consultant found that the aerodrome was in a safe and serviceable condition, and the apron was in good condition. There was no reference to the presence of the mats or their condition.
The consultant advised that conveyer belts had been used in a similar way on the movement areas of other aerodromes of comparative size to Fortnum Aerodrome and some certified aerodromes where larger aircraft had been operated. Although the consultant had heard that incidents had occurred, no record of a similar occurrence was found and the mat coming loose to strike the propeller was a surprise.
In the Fortnum aerodrome risk assessment compiled by the aerodrome operator, foreign object damage was identified as a hazard that was controlled through the daily/weekly inspections, restricted airside access, and monitoring during aircraft movements.
For reference, the regulatory guidance for inspection of certified aerodromes (AC 139.C-03v1.0) specified that serviceability inspection of the apron should check the surfaces, including the aircraft parking positions for surface break up and foreign object debris (FOD).
Aircraft damage
In addition to the detached propeller blade (Figure 3), other damage included:
another propeller blade snapped approximately 250 mm from the blade tip
left engine propeller governor control arm fracture, with associated damage to top forward cowling
buckling to the left engine firewall
cracking to the nacelle structure adjacent to the left engine mount.
Figure 3: Propeller hub and detached propeller
Source: Westgold Group
Aircraft operator information
The aircraft operator advised they had been operating 6 weekly flights into Fortnum Aerodrome for about 3 years and pilots had been instructed to park with the propellers over the matting to prevent foreign object damage to the propellers. There was no record provided of any communications between the aircraft operator and the aerodrome operator related to the condition of the matting. The apron matting had not been identified as a risk in the operator’s safety management system.
Other occurrences
A search of the ATSB database was conducted for events between 2012 and 2022 involving mats or conveyor belt used on aircraft movement areas. This identified 3 other occurrences involving a helicopter that resulted in contact between matting and the main rotor blades and 2 aeroplanes that resulted in propeller strikes.
By aligning the centreline of the aircraft with the central white line, the aircraft was positioned with the left propeller disc located above the intersection of two conveyor belts. It is evident that the airflow produced at the propeller tips produced a lifting force on the matting and the corner nails of the inner belt were not sufficiently secured to hold it. As a result, the corner of the belt was drawn into the propeller arc and one propeller blade was sheared off near the hub and another blade was damaged. With one blade detached the propeller was severely unbalanced and generated significant engine vibration that damaged the aircraft.
Although it is not possible to establish the condition of the inner belt before the accident, the aerodrome reporting officer and flight crews did not notice anything amiss. If other crews were also using the central white line to position aircraft over this matting, on those occasions one propeller would generally be placed over the intersection of the belts and there might have been progressive degradation of mat security. The crew did not have the opportunity to look at the matting as they might have done before an engine start in the same position.
Additionally, the aerodrome operator’s risk assessment did not identify the matting as a potential propeller strike hazard, nor did the previous audit by the aerodrome consultant. This was probably related to the absence of specifications and specific inspection requirements for the non-standard apron surface. It is also possible that the matting security had deteriorated since the risk assessment and audit were carried out.
As this occurrence demonstrates, the consequences of a propeller strike can be serious, and operators of aircraft and aerodromes are advised to review the use of any non-standard surfaces for aircraft movement areas.
Findings
ATSB investigation report findings focus on safety factors (that is, events and conditions that increase risk). Safety factors include ‘contributing factors’ and ‘other factors that increased risk’ (that is, factors that did not meet the definition of a contributing factor for this occurrence but were still considered important to include in the report for the purpose of increasing awareness and enhancing safety). In addition, ‘other findings’ may be included to provide important information about topics other than safety factors.
These findings should not be read as apportioning blame or liability to any particular organisation or individual.
From the evidence available, the following findings are made with respect to the foreign object damage involving Beech 1900D, VH-NYA on 17 November 2022.
Contributing factors
As the flight crew was conducting pre-take-off checks, the end of conveyer belt matting under the left propeller was drawn into the propeller arc, resulting in a sheared propeller blade and vibration damage to the aircraft.
The conveyer belt matting installed on the aerodrome apron was a non-standard method to prevent propeller damage and was not subject to any material specifications, installation instructions, or maintenance requirements.
Under section 26 of the Transport Safety Investigation Act 2003, the ATSB may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. That section allows a person receiving a draft report to make submissions to the ATSB about the draft report.
A draft of this report was provided to the following directly involved parties:
The submissions were reviewed and, where considered appropriate, the text of the report was amended accordingly.
Purpose of safety investigations
The objective of a safety investigation is to enhance transport safety. This is done through:
identifying safety issues and facilitating safety action to address those issues
providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
Terminology
An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Ownership of intellectual property rights in this publication
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Occurrence summary
Investigation number
AO-2022-059
Occurrence date
17/11/2022
Location
Fortnum Aerodrome
State
Western Australia
Report release date
30/05/2023
Report status
Final
Investigation level
Short
Investigation type
Occurrence Investigation
Investigation status
Completed
Mode of transport
Aviation
Aviation occurrence category
Foreign object damage / debris
Occurrence class
Accident
Aircraft details
Manufacturer
Beech Aircraft Corp
Model
1900D
Registration
VH-NYA
Serial number
UE4
Aircraft operator
Penjet Pty Ltd
Sector
Turboprop
Operation type
Part 121 Air transport operations - larger aeroplanes
Rail operator Aurizon has taken steps to better identify out-of-gauge loads at its Stuart terminal, after a bridge was damaged in Rockhampton due to an overheight trailer;
The ATSB encourages operators to identify and embrace cost-effective ways to enable rail staff to more accurately identify loads with the potential to cause damage or injury during transit.
A Rockhampton railway bridge was damaged by a tipping trailer that had been loaded onto a freight train despite being too high for the rail network, an Australian Transport Safety Bureau report details.
The tipping trailer was loaded onto the train at the Stuart terminal, near Townsville, on 16 September 2021.
“Stuart terminal was cooperatively operated between Linfox and Aurizon, with Linfox responsible for the movement of road freight to and from the terminal, and Aurizon conducting the loading of rail wagons and rail operations,” ATSB Director Transport Safety Dr Michael Walker explained.
“The tipping trailer was a Linfox asset rather than customer freight and, as such, it was not managed through Linfox’s normal process, which required any non-standard loads to be referred to management for approval.”
The trailer, when loaded onto a rail wagon, reached a height of 4.41 m above the rail – almost 60 cm over the maximum permissible height on the North Coast Line from Townsville to Brisbane.
“This was not identified by the heavy lift (forklift) operator during loading, likely because they did not have a nearby reference and were not expecting the load would be out of gauge,” Dr Walker said.
“The rail operator also did not routinely apply a process at the Stuart terminal to verify that the dimensions of non-standard loads were within the permissible profile.”
During the subsequent journey to Brisbane, the trailer’s hydraulic lifting post collided with the overhead structure of Alexandra Bridge in Rockhampton, resulting in damage to both the bridge and the trailer. There were no injuries or damage to the train.
Since the incident, Aurizon has installed a jangle bar at Stuart terminal, and is assessing options for automated controls.
The rail operator has also updated its freight management system and booking system, and implemented procedures for the identification of non-standard freight.
The ATSB encourages all operators to identify and embrace cost-effective ways to enable rail staff to more accurately identify loads with the potential to cause damage or injury during transit.
“In the absence of measuring equipment, or nearby objects of a known and relevant height, it is difficult to accurately estimate the dimensions of loaded freight, especially when judging the height of tall freight from ground level,” Dr Walker said.
“Tools to alleviate this limitation will be significantly more accurate and come with minimal cost.”
Interim report details investigation’s progress so far;
Report details that about 10 minutes into the flight, the pilot noticed a gap between the vent panel and the edge of its vent aperture;
Incident balloon was the only one of its kind with the modified vent design produced by the manufacturer.
The Australian Transport Safety Bureau has provided an update on its ongoing investigation into the collision of a hot air balloon, with 13 passengers and a pilot on board, with buildings in suburban Melbourne.
The interim report details evidence gathered so far in the ATSB’s investigation. It contains no analysis or findings, which will be detailed in the investigation’s final report.
The balloon had departed from Royal Park on the morning of 20 April 2022, for an intended destination of Moorabbin Airport.
“Passenger photos showed the vent panel, designed to control the release of air from the top of the balloon was almost, or already, pushing through its opening at normal operating temperatures,” ATSB Director Transport Safety Stuart Macleod said.
About 10 minutes into the flight, the pilot noticed a gap between the panel and the edge of its vent aperture. The pilot was unable to seal it using the deflation system lines.
“As the flight progressed, the gap between the vent aperture and the vent panel expanded and altitude control became increasingly difficult,” Mr Macleod said.
After an unsuccessful attempt to land in Fawkner Park, the pilot tracked the balloon to the south with the intent to land at Elwood Beach. Before reaching the beach, however, with the pilot unable to maintain altitude, the balloon would land outside the entrance of an apartment building in Elwood.
Three passengers sustained minor injuries.
The interim report notes the accident flight was the balloon’s first since manufacture, and that prior to its manufacture in 2021, the balloon’s operator requested a larger vent (both the vent aperture and panel) to increase the balloon’s descent performance.
As such, the incident balloon was the only one of its kind with the modified vent design produced by the manufacturer.
Following the incident, the ATSB arranged for the balloon’s deflation system to be tested. During that testing, the balloon was tethered to the ground and its envelope inflated.
“During the test, at an internal envelope temperature of about 90 °C, which was below the maximum allowable temperature of 124 °C, edges of the vent panel between the vertical load tapes pushed up through the aperture creating many gaps for internal envelope air to vent out,” Mr Macleod noted.
“Attempts to seal the gaps using the parachute vent line and white line were unsuccessful, and at higher temperatures, the gaps became larger and more numerous.”
According to the pilot of the incident flight, who witnessed the testing, and an analysis of passenger video, the vent gaps were very similar to those observed during the incident flight.
Mr Macleod noted that as the investigation continues the ATSB will examine the balloon manufacturer’s processes and procedures for modifying the balloon’s design, and the balloon’s acceptance into service.
A final report will be released at the conclusion of the investigation.
“However, should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.”
At the time the clearance was issued for the B737 to cross the runway, an Airbus A380-841 (A380) aircraft, registered 9V‑SKQ and operated by Singapore Airlines, had just commenced its take-off on runway 34L and was accelerating through a groundspeed of about 40 kt. The B737 was on taxiway Golf and about 300 m from runway 34L when its flight crew saw the A380 on initial climb. They remarked to each other that this was unusual and thought they had been instructed to cross runway 34L ahead. They contacted the SMCE and received confirmation they were clear to cross the runway and taxied to their parking bay. The B737 did not infringe on the 34L runway strip and there was no runway incursion.
Figure 1 depicts the relative locations between runways 25 and 34L, representative ground tracks for the B737 and A380 together with the location of taxiways Yankee and Golf.
Figure 1: Extract from Sydney Airport aerodrome chart with runway (RWY) orientation and taxiway (TWY) layout
Source: Airservices Australia, annotated by the ATSB
Runway and taxiing operations
Strong westerly winds prevailed during the afternoon, with runway 25 being used as the duty runway for both arriving and departing aircraft. For aircraft requiring the use of a longer runway, 34L was available on request but was deactivated when not operationally required.
With runway 25 being used for arrivals, flight crews of landing domestic jet aircraft were typically required to vacate via taxiway Yankee or if operationally required, taxiway Alpha. The flight crew were then to contact the SMCE, who would issue the taxi clearance to the domestic apron, including the clearance to cross runway 34L.
Similarly, the surface movement controller west (SMCW) was responsible for coordinating taxi clearances for aircraft using the international apron. The SMCW had provided approval for the flight crew of the A380 to push back from their parking bay and issued the clearance to taxi to the runway threshold for 34L.
Activation of runway 34L and take-off of the A380
The ADC had activated runway 34L using the tower control and monitoring system. Soon after, the flight crew of the taxiing A380 had called ready for take-off. With the activation of the runway, the responsibility for separating aircraft and vehicles using that runway transferred to the ADC, including approving requests to cross or enter the active runway.
The SMCE and SMCW were alerted to the runway activation by notification chimes at their controller positions, which required their acknowledgement and insertion of a ‘34L ACTIVE’ strip in their flight progress strip board.[4] The SMCW and SMCE in turn used their hotline to the ADC to acknowledge the changed status of the runway and provide relevant details for aircraft or vehicles operating on that part of the aerodrome’s movement area. When the SMCE acknowledged the runway activation and placed the relevant status strip into their flight progress strip board, they requested (and were issued) clearance from the ADC, for an aircraft under tow to cross runway 34L.
After activating the runway, the ADC instructed the flight crew of the A380 to line-up and hold position. Soon after, the B737 flight crew were transferred to the tower frequency and established contact with the ADC. About a minute later, the ADC issued the B737 flight crew a landing clearance and passed information about the A380, which was lining-up on the crossing runway to hold position. The ADC issued the A380 flight crew their clearance to take-off as the B737 passed through 34L during its landing roll.
After landing and vacating the runway, the B737 flight crew transferred to the SMCE frequency. The SMCE subsequently issued the B737 flight crew their taxiing instructions and clearance to cross runway 34L, without coordinating the crossing of the active runway with the ADC.
Sighting limitations
The B737 operator required its flight crews to scan the runway approach path and runway environment prior to entering any runway, to identify potential traffic that could conflict with their safe crossing. Flight crew and airside vehicle drivers crossing runway 34L in the vicinity of taxiway Golf had several sighting limitations along the runway to the south, principally due to reprofiling of terrain that had occurred with the construction of General Holmes Drive (which passes under the airport south of taxiway Golf).
The ATSB examined any sighting limitations based on the time a B737 flight crew would have been scanning the runway environment as they approached the taxiway hold position and the performance of the A380 on its take-off roll. The ATSB found that the lower fuselage, wings and landing lights of an A380 would be shielded by terrain during the first part of the take-off roll and not visible to flight crew or vehicle operators approaching runway 34L along taxiway Golf. In addition, the oblique viewing angle of an A380 upper fuselage and tail at the maximum sighting range made it harder to identify aircraft during the early stages of the take-off roll.
Stop bar lighting and procedures
Operating the stop bars and runway guard lighting
The airport’s ground-based infrastructure included runways, taxiways and the associated airfield lighting systems, which were maintained by Sydney Airport Corporation Limited. The intersections of taxiways with runways were equipped with stop bar lighting, runway guard lighting[5] and movement area guidance signs. Those systems were intended to help reduce the incidence of runway incursions.[6]
Local procedures at Sydney required taxiway stop bars to be illuminated at all runway crossing points, irrespective of runway status.[7] Consequently, an air traffic controller was required to deactivate the taxiway’s stop bar for every clearance issued for a runway crossing or entry by taxiing aircraft or authorised vehicles. The responsible controller selected and deselected the taxiway’s stop bar using the airfield ground lighting (AGL) panel.[8] The location of the stop bar at the intersection of taxiway Golf with runway 34L is depicted in Figure 1.
As noted previously, when runway 34L was active, the ADC was responsible for separating aircraft and vehicles, and for operating the stop bars. When runway 34L was inactive and the runway had been released by the ADC, the SMCE in this case was responsible for both deactivating the stop bars and issuing the runway crossing clearance to flight crews of aircraft taxiing to the domestic terminal.
Advanced surface movement guidance and control system
Sydney Airport was equipped with an advanced surface movement guidance and control system (A-SMGCS) that provided tower controllers a surveillance picture of the airport’s surface movement areas. The A‑SMGCS interfaced with several related systems, including the airport surveillance radar, flight data system and AGL systems.
Data was shown on the A-SMGCS controller’s working position display, which included a map of the airport environment (runways, taxiways and apron/ramp), together with the position/identification of aircraft/vehicles and information about the status of the various related systems. The system also had several safety logic functions that included closing/opening a runway, airport configuration, operator role (including control over runways) and runway alerts and warnings. The safety logic detection parameters would activate an alert or warning when detecting a conflict between tracks on the runway. In this instance, a safety alert was not generated due to the B737 not entering the runway strip while the A380 was on its take-off roll.
Manual of Air Traffic Services procedures
The Manual of Air Traffic Services (MATS) procedures required that all runways in use were controlled by the relevant ADC and activation of all stop bars at the holding positions associated with that runway (where installed). The ADC controlling the runway was responsible for issuing clearances to cross or enter the runway and temporarily deactivating the stop bar at that relevant holding position to indicate the traffic may proceed. Stop bars were installed on the runways at Brisbane, Canberra, Melbourne, Perth and Sydney airports.
At Canberra, Melbourne and Brisbane, the stop bars were only activated when the runway was in use. When runways at those airports were not in use, the stop bars were deactivated and the inactive runway did not need to be released to the SMC.[9] This was consistent with the guidance provided in MATS.
For Sydney and Perth airports, stop bars were continuously active irrespective of the runway status. When a runway was not in use, the ADC released the runway to the SMC who was then responsible for authorising flight crews or vehicle drivers to cross/enter the runway and also operated the stop bar lighting system.[10] While this was inconsistent with MATS, Airservices Australia, the airport operators and local users had implemented local procedures to facilitate the activation of stop bars on all runways, irrespective if they were in use and under the control of an ADC.
Operational standards review
Airservices Australia’s Sydney tower unit had been subject to a routine national check and standardisation supervisor review in June 2022, covering the period from completion of the last review in May 2019. The purpose of review was to ensure that the unit was meeting required documentation and operational standards, together with consideration of any local unit procedures that could be considered for national implementation.
The review identified that Sydney tower operated stop bars differently to other airports, including their use when the runway was not being used, when stop bar activation was not required. That finding was not identified to be safety critical but recommended that the process for stop bar operation should be standardised. The actions identified to address the finding included a clarification to MATS that the controller with control of the runway was to have sole ownership of the associated stop bars and that the stop bar procedures for Sydney were to be aligned to the national standardised practice.
The revised procedures were subsequently implemented in March 2024. In addition, in July 2024, the AGL system was updated, enabling the jurisdictional transfer of stop bar operation to the ADC at times the runway was in use and at those times, the stop bars could not be deactivated by the SMC.
Surface movement controller east information
The controller performing SMCE duties at the time of the incident had more than 30 years’ experience and had worked in Sydney Tower for most of that period. The controller was rated for all positions in Sydney Tower and previously held ratings for training, checking and supervising tower operations. They had successfully completed 2 days of their regular scenario based tower simulator training about 10 days prior to the incident and their 6-month proficiency check in August 2022.
The SMCE had signed on for duty at 1320 and felt they were adequately rested and fit for their duty. The controller had occupied 2 other positions (with 30-minute breaks between each position) prior to commencing the SMCE duties. At the time of the incident, the controller had been performing SMCE for about 1 hour 15 minutes and recalled feeling 4-a little tired, less than fresh.[11] The ATSB reviewed the controller’s roster for a 6-week period, however, there was insufficient evidence to suggest that the controller’s performance was affected by fatigue.
The incident flight was the first activation of runway 34L for a departing or arriving aircraft while the controller was in the SMCE position. Prior to this, the SMCE had cleared the flight crew of about 18 landed jet aircraft to taxi to the domestic terminal. These all included a clearance to cross the inactive runway 34L and deselection of the stop bars. This was in addition to the SMCE’s other workload, which included coordinating ground movements for arriving turboprop aircraft, departing aircraft (including approving pushbacks from the parking bay), and other vehicles operating on the airport.
ATSB observations
The ATSB made the following observations regarding the incident:
When the flight crew of the B737 landed and contacted the SMCE for taxiing instructions and a clearance to their parking bay, the SMCE did not correctly recall the changed status of runway 34L. Subsequently, they deactivated the stop bar and issued a clearance for the B737 to cross the active runway. However, as the runway was active, those actions were the responsibility of the ADC.
Although the SMCE was using the runway 34L active strip in the flight progress strip board, clearing landed jet aircraft to the domestic apron, deselecting the stop bar lighting in the AGL panel and crossing them through the inactive runway 34L was a repetitive task and familiar in nature. This increased the likelihood that if a change to the runway status was overlooked, it would result in the deactivation of the stop bar lighting and the issuing of an incorrect clearance.
The design of the AGL panel at the time of the incident enabled the SMCE to deactivate a stop bar of an active runway, for which they did not have responsibility for.
At the time of publication for this notice, only 5 Australian airports were fitted with stop bars. The procedures for using stop bars on inactive runways varied between these airports.
The routine use of stop bars on an inactive runway was inconsistent with the procedures indicated in MATS. This influenced the SMCE deactivating the stop bars and issuing the clearance for the B737 flight crew to cross the runway while it was being used for take-off by the A380. Alternately, if the stop bars were only used when the runway was in use, the stop bars would have been activated by the ADC when resuming control for the runway. Even if the SMCE had incorrectly assessed the status of the runway and issued a clearance to cross (what they thought was an inactive runway), the stop bars would have remained illuminated, indicating to the flight crew they could not cross.
Safety action
Procedural changes to the stop bar operation at Sydney Airport and implemented since this incident are as follows:
If runway 34L is inactive and the ADC has not released the runway to the SMC, the ADC retains stop bar ownership and is required to approve all runway crossings of the inactive runway. The SMC is unable to operate the stop bar lighting controls in the AGL panel.
If runway 34L is inactive and the ADC has released the runway to the SMC, access for the SMC to operate the stop bars is enabled in the AGL panel when the ADC selects the relevant runway mode. The SMC is responsible for issuing runway crossing clearances and operates the stop bars without requiring coordination with the ADC.
When runway 34L has been released to the SMC and the ADC takes ownership back, the ADC amends the operating mode in the AGL panel and the SMC is then unable to operate the stop bar lighting controls in the AGL panel. The SMC coordinates runway crossings with the ADC, who operates the stop bars.
When runway 34L is active, the ADC retains stop bar jurisdiction and the SMC is unable to operate the stop bar controls in the AGL panel. The SMC requests clearances for runway crossings from the ADC, and when the ADC approves the crossing and deselects the stop bar, the SMC issues the clearance for the aircraft or authorised vehicle to cross the runway.
Safety message
Although stop bars were principally introduced to help reduce runway incursions by taxiing aircraft and authorised airside vehicles during periods of low visibility, they are also used effectively at other times to help reduce the risk of an incursion on an active runway. The ATSB also notes that, at Australian airports where stop bar lighting is only activated at times the runway is active, the associated procedure introduces an additional risk control by removing the coupling between an SMC’s deactivation of stop bars and their issuing of clearances to cross the inactive runway. This reduces the potential for an SMC to deactivate stop bars and issue an incorrect clearance to cross an active runway, with taxiing flight crew and vehicle drivers required to stop at all illuminated stop bars.
Reasons for the discontinuation
Based on a review of the available evidence and the implementation of safety action by Airservices Australia and Sydney Airport Corporation Limited, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues or important safety lessons.
The ATSB strives to use its limited resources for maximum safety benefit, and considers that in this case, the change to stop bar procedures at Sydney Airport and the change to the airfield ground lighting system has likely reduced the risk of a similar incident occurring. Consequently, the ATSB discontinued the investigation.
[1]The function of aerodrome control for the purpose of aircraft taking-off, landing and transiting the airspace associated with the control zone was provided by air traffic controllers located in the airport’s control tower. At Sydney Airport, there was provision for several aerodrome control positions, depending on the number of runways in use and any additional coordination that was required for arriving and departing aircraft.
[2]The function of airport surface movement control was provided by an air traffic controller located in the airport’s control tower. At Sydney Airport, there were 2 surface movement control positions (east and west). The surface movement controller coordinated the ground movement of aircraft and vehicles.
[3]When activated, the stop bars comprise a row of red lights inset into the surface of the taxiway, at an angle of 90° to the taxiway centreline. The inset lighting was augmented with a red above ground light either side of the taxiway, abeam the stop bar position. Aircraft or authorised vehicles must not cross the stop bars without both an air traffic control clearance and the red stop bar lights being extinguished.
[4]The flight progress strip board formed part of the controller’s scan when issuing clearances to cross inactive runways.
[5]Runway guard lighting comprised pairs of above ground flashing amber lights on each side of the taxiway, which continuously flashed to indicate a runway was ahead. Each amber light in the pair flashed alternately so that one light in each pair was always illuminated. Runway guard lighting installations are also known as ‘wig wags’.
[6]Stop bar and runway guard lighting was initially designed to reduce the risk of runway incursions during periods of low visibility. Those lighting systems are also used more generally to help mitigate the risk of runway incursions that could occur at other times.
[7]When not being used operationally, a runway could be inactivated and responsibility for aircraft and vehicles using that part of the movement area transferred to the surface movement controllers.
[8]The airfield ground lighting system was part of the airport’s operating infrastructure, which was provided/maintained by Sydney Airport Corporation Limited.
[9]At Canberra airport, stop bars were activated when runways were closed by NOTAM. In addition, when the tower was closed overnight, the stop bars were deactivated and flight crews were responsible for their operations at the uncontrolled aerodrome.
[10]At Perth and Sydney airports, stop bars were also activated when runways were closed by NOTAM.
[11]The score is based on the Samn-Perelli 7-point fatigue scale, where 1 indicates fully alert and 7 indicates completely exhausted.
Occurrence summary
Investigation number
AO-2022-062
Occurrence date
14/11/2022
Location
Sydney Airport
State
New South Wales
Report release date
30/01/2025
Report status
Discontinued
Investigation level
Short
Investigation type
Occurrence Investigation
Investigation status
Discontinued
Mode of transport
Aviation
Aviation occurrence category
ANSP info/procedural error
Occurrence class
Incident
Highest injury level
None
Aircraft details
Manufacturer
The Boeing Company
Model
737-8SA
Registration
VH-IWQ
Serial number
44225
Aircraft operator
Virgin Australia Airlines
Sector
Jet
Operation type
Part 121 Air transport operations - larger aeroplanes
On the afternoon of 30 November 2022, the student pilot of a Hughes Helicopters 269C, registered VH-OBK, was returning to Moorabbin following the pilot’s second solo navigation training flight.
As the helicopter approached the landing area, the approach became unstable, and the pilot commenced a go‑around. As the helicopter climbed to about 650 ft above ground level, the pilot commenced a right turn onto the downwind leg of the circuit to position for a second approach for landing. Shortly after, the pilot noticed reduced performance and decided to continue the turn back toward the airport.
The helicopter continued to lose height and, recognising that a forced landing was required, the pilot turned the helicopter left toward a school ground to attempt an autorotation landing. The helicopter subsequently collided with the rooftops of 2 houses just short of the school ground. The pilot sustained serious injuries and the helicopter was substantially damaged.
What the ATSB found
The ATSB found that as the helicopter climbed to about 650 ft above ground level, the engine lost power. The reason for the engine power loss was not determined.
The power loss was not immediately recognised which limited the opportunities for a safe forced landing. During the forced landing, the helicopter did not have sufficient height to reach the selected landing area and collided with rooftops.
Safety message
This accident highlights the challenges pilots face when confronted with a loss of engine power at low level and with few suitable landing areas available.
…before conducting a take-off from any aerodrome, pilots of single-engine helicopters make themselves aware of the areas that would be suitable, from the lift-off point to a safe manoeuvring height, to conduct a forced landing in the event of engine failure after take-off.
These challenges of managing a power loss are increased for an inexperienced student pilot. While in this case, the selected landing location was unable to be reached, importantly, the pilot maintained control of the helicopter to maximise survivability.
The navigation exercise was conducted without incident and at 1255, the helicopter returned to Moorabbin where air traffic control provided the pilot with clearance to conduct a visual approach to the southern apron.
At 1300, the helicopter approached the apron to land. At a height of about 20 ft above ground level (AGL), the approach became unstable, and the pilot accelerated the helicopter slightly to stabilise the approach. The acceleration moved the helicopter further along the apron where the pilot judged that insufficient space remained to conduct a safe landing so they commenced a go‑around.
During the go-around, the pilot observed factories located immediately south of the apron and made a left turn, opposite to the right circuit direction, to provide sufficient room to climb over the factories (Figure 1). This left turn unintentionally took the helicopter toward the departure path of the active runway 17 right, and air traffic control instructed the pilot to make an immediate right turn. The pilot turned the helicopter right and continued climbing on the crosswind leg of the circuit.
Figure 1: Go-around flight path of VH-OBK (Moorabbin airport)
Source: Google Earth, annotated by the ATSB
As the helicopter climbed to about 650 ft AGL, the pilot commenced a right turn onto the downwind leg of the circuit.[1] During the turn, the pilot noted reduced helicopter performance and decided to continue the right turn to take the helicopter back toward the airport.
The pilot recalled that there were no unusual engine sounds or vibrations but that regular communications between air traffic control and other aircraft limited their ability to hear the engine. The pilot reviewed the instrumentation to attempt to identify a reason for the performance loss. The pilot observed the helicopter’s airspeed had increased from the climb speed of 55 kt to between 70‑80 kt and that the manifold pressure had increased above the targeted 24 inches of mercury (Hg) to 29 inches Hg. The engine RPM reading was not checked.
The pilot then adjusted the pitch attitude of the helicopter to that which normally provided a climb speed of 55 kt and lowered the collective[2] slightly to reduce the observed high manifold pressure reading. Following these actions, the helicopter continued descending as it tracked toward the airport.
As the aircraft descended to about 100 ft AGL, the pilot recognised that the descent rate had increased, and a forced landing was required. At that time, a football oval was likely positioned under or slightly ahead and to the right of the helicopter, but the pilot did not see it possibly because it was obscured by the airframe or instrument panel. The pilot identified a water catchment and a school ground as suitable areas for a forced landing and turned the helicopter left toward the school ground to attempt an autorotation[3] landing (Figure 2). The helicopter did not have sufficient height to reach the school ground and collided with the rooftops of 2 houses. The pilot sustained serious injuries and the helicopter was substantially damaged.
A meteorological report for Moorabbin Airport, recorded at 1300, included a south-westerly wind of 11 kt, visibility greater than 10 km, no cloud, a temperature of 17 °C, and a mean sea level air pressure of 1,018 hectopascals.
The estimated air pressure at 650 ft above mean sea level (600 ft AGL) was 996 hectopascals (29.4 inches Hg).[4]
Aircraft details
VH-OBK was a 3-seat Hughes Helicopters 269C helicopter, manufactured in 1980. The helicopter was powered by a 190 horsepower Textron Lycoming HIO-360-D1A, four-cylinder, fuel injected piston engine. Engine power was transmitted via a belt drive transmission to the main transmission and tail rotor drive shaft. The belt drive assembly incorporated an overrunning clutch to permit autorotation without driving the belts or engine.
The helicopter was not fitted with a low rotor RPM aural warning system, nor was it required to be.
Using information provided by the aircraft operator, the ATSB calculated that the autorotative range from 650 ft AGL was about 0.26 nm (490 m) with no wind and about 0.32 nm (590 m) with a 11 kt south-westerly tail wind.
Site and wreckage information
The helicopter impacted 2 houses immediately adjacent to the school ground targeted for the forced landing (about 600 m from the estimated position of the power loss). The helicopter came to rest embedded in the roof of one of the houses. After recovery of the wreckage, an inspection of the helicopter’s fuel tanks found at least 60 litres of fuel on board.[5]
Figure 3: Accident site
Note: The forward section of the fuselage was cut away by first responders to facilitate removal of the pilot.
Source: Victoria Police, annotated by the ATSB
A detailed examination of the airframe or engine was not performed. However, a visual inspection of the engine cooling fan and fan shroud indicated that the engine was not running at the time of the accident. The degree of damage to the rotor blades also indicated that the engine was providing little or no power.
Witness information
Two Moorabbin air traffic controllers observed the accident. One was located within the control tower, and the other was on a break, walking about 650 m north-east of the accident site. The controller on break noted that prior to the accident, the helicopter’s descent path was shallower than that of a normal autorotation and no engine noise was heard. The controller in the tower also noted the shallow descent path.
The shallower‑than‑expected descent profile observed by the witnesses familiar with the helicopter’s autorotative descent profile, may have been due to the beneficial effect of the pilot pitching the helicopter up to reduce the airspeed from 70‑80 kt to the target airspeed of 55 kt. After the accident, a visual inspection of the engine cooling fan and shroud identified no rotational damage, similarly indicating that the engine was not running at the time of the accident.
There were no reported actions made that may have led to the power loss and the helicopter had sufficient fuel on-board. There were no other reported indications of a fault with the engine. A detailed examination of the engine and airframe was not performed, limiting the ability to identify the reason for the power loss.
The engine power loss occurred at low height over a densely populated area presenting a challenging scenario for the inexperienced student pilot. The pilot did not immediately identify that power was lost and attempted to return to the airport while troubleshooting the reduced helicopter performance. During this time, the helicopter passed 2 suitable forced landing sites (Figure 4).
Figure 4: Flight path of VH-OBK following the engine power loss
Source: Google Earth, annotated by the ATSB
When the pilot recognised that a forced landing was required, the football oval was likely the closest suitable area, but the pilot did not identify the oval, possibly due to it being obscured by the airframe or instrument panel. The pilot identified the school ground and attempted a landing there. However, the helicopter did not have sufficient height to reach the selected site and the helicopter collided with rooftops. While the helicopter did not reach the intended area, the pilot maintained sufficient control of the helicopter and rotor RPM to conduct an autorotation landing into the rooftops, which maximised survivability.
Findings
ATSB investigation report findings focus on safety factors (that is, events and conditions that increase risk). Safety factors include ‘contributing factors’ and ‘other factors that increased risk’ (that is, factors that did not meet the definition of a contributing factor for this occurrence but were still considered important to include in the report for the purpose of increasing awareness and enhancing safety). In addition ‘other findings’ may be included to provide important information about topics other than safety factors.
These findings should not be read as apportioning blame or liability to any particular organisation or individual.
From the evidence available, the following findings are made with respect to the collision with terrain involving Hughes Helicopters 269C, VH-OBK near Moorabbin Airport, Victoria on 30 November 2022.
Contributing factors
As the helicopter climbed to about 650 ft above ground level, the engine lost power. The reason for the power loss was not determined.
The power loss was not immediately recognised which limited the opportunities for a safe forced landing. During the forced landing, the helicopter did not have sufficient height to reach the selected landing area and collided with rooftops.
Civil Aviation Safety Authority 2022, Advisory Circular AC 91-29 v1.1 Guidelines for helicopters -suitable places to take off and land, July 2022.
Submissions
Under section 26 of the Transport Safety Investigation Act 2003, the ATSB may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. That section allows a person receiving a draft report to make submissions to the ATSB about the draft report.
A draft of this report was provided to the following directly involved parties:
operator
pilot’s instructor
pilot
air traffic control witnesses.
Submissions were received from the:
operator
pilot’s instructor
pilot.
The submissions were reviewed and, where considered appropriate, the text of the report was amended accordingly.
The objective of a safety investigation is to enhance transport safety. This is done through:
identifying safety issues and facilitating safety action to address those issues
providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
Terminology
An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
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Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work.
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Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
[1] The altitude for the downwind leg of the circuit for helicopters at Moorabbin Airport was 700 ft above mean sea level (650 ft AGL).
[2] Collective: a primary helicopter flight control that simultaneously affects the pitch of all blades of a lifting rotor. Collective input is the main control for vertical velocity.
[3] Autorotation is a condition of descending flight where, following engine failure or deliberate disengagement, the rotor blades are driven solely by aerodynamic forces resulting from rate of descent airflow through the rotor. The rate of descent is determined mainly by airspeed.
[4] The International Standard Atmosphere (ISA) provides hypothetical standard temperatures and pressures at specified altitudes. ISA conditions are used as a datum for calculating aircraft performance data. The ISA states that air pressure reduces by 1 hectopascal for each 30 ft increase in altitude.
[5] The helicopter was fitted with a main and auxiliary fuel tank. These tanks were interconnected and acted as one fuel tank.
Occurrence summary
Investigation number
AO-2022-063
Occurrence date
30/11/2022
Location
Near Moorabbin Airport
State
Victoria
Report release date
30/03/2023
Report status
Final
Investigation level
Short
Investigation type
Occurrence Investigation
Investigation status
Completed
Mode of transport
Aviation
Aviation occurrence category
Collision with terrain
Occurrence class
Accident
Highest injury level
Serious
Aircraft details
Manufacturer
Hughes Helicopters
Model
269C
Registration
VH-OBK
Serial number
1190855
Aircraft operator
The Helicopter Group
Sector
Helicopter
Operation type
Part 141 Recreational, private and commercial pilot flight training
The ATSB collects, holds and uses a range of information for the purposes of improving transport safety. The ATSB is a part of Australia's aviation safety system, and the information gathered by the ATSB may be provided to other agencies for the specific purpose of maintaining and improving aviation safety. It is an additional legislative function for the ATSB to cooperate with these agencies.
Mandatory reporting
A principal source of safety information is the mandatory reporting scheme established under the Transport Safety Investigation Act 2003 (TSI Act). The scheme gathers information on occurrences which endanger or could endanger aviation safety. The information is gathered so that it can be used by those with responsibilities within the safety system to discharge their responsibilities to maintain and improve aviation safety.
The scheme requires 'responsible persons' (including aircraft crew, owners, operators, air traffic controllers, licensed aircraft maintenance engineers, ground crew and airport operators) to notify the ATSB of accidents and safety incidents ('safety occurrences').
Where the duty to report rests with an individual, it can be fulfilled by the individual notifying the operator who employs them. The operator then has a duty to pass the information on to the ATSB.
Use of safety information by the ATSB
The ATSB uses safety information to assist in its determination of what to investigate for the purposes of improving safety.
Any information that is the subject of an ATSB investigation will only be used in accordance with the provisions of the TSI Act which provides significant protections to information acquired by the Bureau in the course of its investigation.
The ATSB also uses safety information for the purposes of safety research and analysis. The results of research and analysis are generally made public, but in such a way that either the information is either de-identified or is otherwise protected.
ATSB and CASA information sharing
The Civil Aviation Safety Authority (CASA) is constituted under the Civil Aviation Act 1988 (CA Act). The primary object of the CA Act is to establish a regulatory framework for maintaining, enhancing and promoting the safety of civil aviation, with particular emphasis on preventing aviation accidents and incidents. CASA's primary function under the CA Act is to conduct the safety regulation of civil air operations in Australia and the operation of Australian aircraft outside Australian territory.
Consistent with the objective of maintaining and improving aviation safety under the Australian aviation safety framework, the ATSB recognises CASA needs access to a range of information about aviation safety occurrences that is collected and held by the ATSB.
What information is shared
The ATSB informs CASA about accidents and serious incidents as soon as the ATSB is informed. The information may contain details such as operator names, registration numbers, times, dates, locations and a description of the event. The ATSB aims, wherever possible, to avoid directly identifying individuals.
CASA is also provided daily with a redacted report of all occurrences entered into the ATSB database. The report contains standard information about occurrences notified to the ATSB, including aircraft registration, so that CASA has enough detail to gather its own information about the occurrence. It does not contain a detailed narrative.
An automated weekly transfer of summaries of information entered in the ATSB's database during that week is also provided to CASA. The aggregate summary does not include identifying information such as aircraft registration, but provides enough information for CASA to be able to analyse safety trends, and to identify actual or potential safety risks to which more immediate attention needs to be directed. Since 1 July 2023, the de-identified occurrence database is being shared via the centralised Aviation Safety Data Sharing Platform.
Aviation Safety Data Sharing Platform
The aviation safety data sharing platform is a collaboration between the ATSB and the Bureau of Infrastructure and Transport Research Economics (BITRE), CASA and Airservices Australia.
Aviation data was already being shared between aviation safety agencies on a regular and ad-hoc basis. The Aviation Safety Data Sharing Platform will streamline and modernise this process to provide this same data in a consistent real-time format, while incorporating additional security controls and privacy measures.
The information shared to the platform between aviation authorities will enable better decisions to be made for policy development, regulatory settings and safety outcomes for the aviation industry and general public.
All agencies involved in this project are ensuring that data shared or analysed within the platform will not be used to identify individuals or firms, or for regulatory and compliance purposes. The existing legislative restrictions on data sharing continue to apply, and agency-specific user access controls are in place in line with relevant privacy and confidentiality standards.
Purpose of information sharing
CASA uses safety information from the ATSB principally for two purposes: to have sufficient information about an occurrence to decide whether to initiate its own, independent regulatory inquiries; and to have access to a database of occurrence information so that trends in aviation safety can be detected and, where necessary, safety action can be taken.
Limits on use of information by CASA
CASA may use information reported under the mandatory scheme as the basis for informing its need to initiate its own inquiries in the interests of safety. However, CASA will not rely on the report in taking action unless it is necessary to do so in the demonstrable interests of safety and where there is no alternative source of the information practicably available to CASA.
CASA will not normally recommend the institution of criminal proceedings in matters which come to its attention only because they have been reported under ATSB's mandatory reporting scheme. The exceptions will be in cases of conduct that should not be tolerated, such as where a person has acted intentionally, knowingly, recklessly or with gross negligence.
In taking any action, CASA will afford affected individuals and organisations natural justice.
This policy is consistent with contemporary practice in leading aviation States. It is also in line with the new ICAO Annex 19 – Safety Management. Standard 5.1.1 of the Annex requires that:
Each State shall establish a mandatory incident reporting system to facilitate collection of information on actual or potential safety deficiencies.
Recommended practice 5.3.1 states:
State authorities responsible for the implementation of the State Safety Program should have access to appropriate information available in the incident reporting systems.
The regulator and the accident investigator both have responsibilities with respect to the implementation of the State Safety Program. This policy outlines what each agency requires accident and incident information for in order to be able to perform their respective complementary functions. It also makes clear what limitations currently govern the use of information by CASA. Having regard to international developments, the ATSB and CASA will seek the views of industry participants and the wider Australian aviation community on the implementation and further development of this policy.
On 18 September 2022, a Jabiru J230-C, registration 24-5067 collided with terrain at Lucyvale, Victoria.
The pilot was fatally injured, and the aircraft was destroyed. Recreational Aviation Australia requested technical assistance from the ATSB to assist in its investigation.
The ATSB was requested to download and recover flight data from the GPS. To facilitate this assistance, the ATSB initiated an external investigation under the provisions of the Transport Safety Investigation Act 2003.
The ATSB has completed its work downloading the recorded flight path data from the supplied Garmin GPS Map 296 unit. A copy of the data and a report detailing the work undertaken by the ATSB was provided to RAAus on 22 December 2022.
