Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

On 2 November 2018 at approximately 1400 Eastern Standard Time (0400 UTC), the crew of a Boeing 717 at Brisbane, Queensland obtained a weather brief on their destination airport, Canberra, Australian Capital Territory.

The weather brief obtained included a TAF^[1] for Canberra aerodrome and the latest TTF^[2] SPECI^[3].

Table 1: MET products obtained by crew

TAF	TAF AMD YSCB 012302Z 0123/0224 32020G35K 9999 -SHRA SCT050 BECMG 0206/0208 32013KT 9999 -SHRA SCT050 FM021500 29014KT 9999 FEW050 BECMG 0222/0224 28015G25KT CAVOK PROB30 INTER 0204/0209 VRB30G45KT 5000 TSRA SCT020 SCT060CB=
TTF	TTF SPECI YSCB 020330Z 33025G40KT 9999 FEW050 BKN100 31/06 Q1012 RMK RF00.0/000.0 FM0330 MOD/SEV TURB BLW 5000FT

The TAF published at 2302 UTC on 01 November 2018 and valid between 0400 and 0900 UTC on 02 November 2018 had a PROB 30 INTER for thunderstorms, which indicated a 30% probability of thunderstorms occurring. The TTF SPECI published at 0330 UTC and valid for 30 minutes after the crew’s scheduled arrival time at 0400 UTC did not include thunderstorms. No TTF SPECI published up to 0600 UTC on that day included thunderstorm.

The crew additionally checked the Bureau of Meteorology’s (BOM) weather radar which confirmed a weather system similar to that of a squall line approaching the Canberra region.

Based on the information published, the crew were inclined to believe that thunderstorms were not prevalent at Canberra, as information published in Aeronautical Information Package (AIP) GEN 3.6.3 states that the “TTF supersedes the TAF for its validly period and is the current forecast for pilots of aircraft whose arrival time falls within the validity period. It should be noted that PROB is not used in TTF (but is included in TAF).”

The aircraft was subsequently required to hold for 35 minutes before landing at Canberra, as the airport was closed due to thunderstorm activity.

Table 2: Timeline of events

Time (UTC)	Event
0359	Weather briefing obtained by crew – included TAF and TTF
0330–0553	TTF between periods 0330 to 0553 include strong wind gusts (up to 40 knots)
0405–0420	Aircraft departs Brisbane
0553	TTF from 0553 shows easing wind conditions (8 knots)
0600	Scheduled time of arrival
0640	Actual arrival time

Figure 1: Geographical Area Forecast (GAF) with highlighted contact details

Safety message

Crew are encouraged to seek further advice if they are in receipt of conflicting meteorological information or have any doubts regarding the accuracy of the published forecasts. Contact details are located at the bottom of the Geographical Area Forecast (Figure 1), which directs pilots to a forecaster for the area.

Whilst it is important to obtain specific information relating to the planned departure and arrival port, it is also important to have a complete picture of the area meteorological conditions to avoid unexpected conditions. Pilots are encouraged to use the wide range of meteorological information available.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

__________

1. Terminal aerodrome forecast (TAF) is a format for reporting weather forecast information, particularly as it relates to aviation.
2. The trend forecast is an aerodrome weather report to which a statement of trend, for the elements wind, visibility, weather and clouds, is appended, forecasting the weather conditions expected to affect the aerodrome for the validity period of the TTF which is normally the three hours following the time of the report.
3. SPECI is special weather report issued when there is significant deterioration or improvement in airport weather conditions, such as significant changes of surface winds, visibility, cloud base height and occurrence of severe weather.

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

On 21 February 2019, a Piper PA-32 6XT departed Orange, New South Wales (NSW) to conduct a private flight to Bankstown, NSW with two crew on board. During approach, at approximately 900 ft above mean sea level at Warwick Farm, the crew detected a vibration. The crew declared a PAN-PAN^[1] to Bankstown tower requesting priority landing. The tower cleared the crew for a straight in approach to runway 11L. The aircraft landed without incident and taxied to parking.

The post-flight inspection revealed the cause of the vibration was due to a 20 cm section missing from one of the propellers. Following the incident, the engineer suspects the likely cause of the propeller section breaking off was due to a stone chip, which developed into a crack as a result of engine operation, which caused stress on the propeller, which subsequently resulted in the propeller failing during flight.

Figure 1: Missing propeller section

Source: Pilot in Command

Safety message

It is important that pilots remain aware that despite conducting comprehensive pre-flight checks, unanticipated failures can still occur during flight. The crew, in this instance, took all possible precautions by following non-normal procedures, providing clear communications to ATC and landing the aircraft as soon as possible.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

__________

1. PAN-PAN - The radiotelephony message PAN-PAN is the international standard urgency signal that the crew on board an aircraft uses to declare that they have a situation that is urgent but, for the time being at least, does not pose an immediate danger to anyone's life or the aircraft itself.

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

On 31 October 2018 at 1300 Western Standard Time, the crew of a Jetstream Series 3200 aircraft was conducting a revenue passenger transport flight between Williamtown, New South Wales and Canberra, Australian Capital Territory. The crew comprised of a captain and a first officer. The captain was pilot flying (PF) and the first officer was pilot not flying (PNF).

Just after take-off from Williamtown, the landing gear was selected up. The nose wheel landing gear light remained green to indicate that it had not retracted. The two main landing gear did retract, but were slower than usual. The flight crew also heard unusual sounds as the landing gear attempted to retract.

The PF decided to conduct a return to Williamtown airport. The PF took over the radios from the PNF, and requested an amended 3,000 ft level off and to remain on the tower frequency, while the PNF conducted the after take-off checklist. The PF instructed the PNF to open the aircraft Quick Reference Handbook and find the checklist for gear locked down. During this time, the PF communicated with air traffic control, to request a circuit for a return to land at Williamtown.

On approach, the PNF selected gear down. The system did not respond to this selection, and the main gear did not extend. The PF instructed the PNF to check the circuit breaker (CB) for the gear, however the PNF could not reach the CB. The PF reset the CB, after which the main gear extended.

The crew then landed the aircraft without incident.

Engineering inspection

Following the incident, inspection of the landing gear revealed that a solenoid on the landing gear selector valve failed when the landing gear was selected up.

Safety message

This incident highlights the value of effective cockpit resource management in response to unexpected events. The PF effectively delegated multiple tasks to the PNF, which enabled the PF to focus on flying the aircraft and communicating with ATC. The PF effectively used the resources available to him in order to gather more information about the problems with the aircraft, by instructing the PNF to consult the Quick Reference Handbook. CASA outlines the importance of using available cockpit resources, and provides practical steps for doing so, in their Human Factors for Pilots booklet on Teamwork.

This incident also highlights the importance of effective pilot decision making to ensuring safe flight. The PF’s decision to return to Williamtown, soon after he had identified that the landing gear was not performing as expected, reduced the risk of the situation deteriorating. Flight crew are encouraged to identify the hazards and risks they encounter during flight, and to make control decisions to minimise those risks where possible. The FAA provides decision-making guidance to pilots in their Aeronautical Decision Making (ADM) training package.

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

On 22 September 2018 at approximately 0613 Eastern Standard Time, a Bell B206 helicopter had departed from a remote location near Yarraden, Queensland. There was one pilot and three passengers on board to conduct a local scenic flight.

Approximately 6 minutes after departure, the engine flamed-out^[1]. The pilot observed the engine out light was flashing on the engine instruments. The pilot subsequently conducted an autorotation^[2] and landed hard resulting in substantial damage to the aircraft. The pilot was uninjured and three passengers sustained minor injuries.

The evening prior to the flight, a support pilot refuelled the helicopter to the sufficient amount for the first flight of the day, to 260 litres. The refuelling was from a drum using an electric fuel pump and PF10-CS water absorbing filters. The support pilot did not inspect the fuel filter bulb at the completion of the refuel due to the lack of ambient light.

Prior to first light on the morning of the flight, the pilot conducted a pre-flight inspection and conducted a fuel drain of the drain points. The pilot inspected the drain and identified it as a liquid that was clear and consistent with no evidence of mixing. The pilot did not test the sample and discarded the liquid.

The drum used to refuel the aircraft the previous evening was inspected. No fuel remained, but 2–4 centimetres of water was identified in the fuel pump filter bowl.

Safety message

Section 5 of the Civil Aviation Order 20.2 Air service operations states that the operator and pilot in command must ensure relevant inspections and tests are made for the presence of water in the aircraft fuel system.

The Order provides the following tips:

“It is important that checks for water contamination of fuel drainage samples be positive in nature and do not rely solely on sensory perceptions of colour and smell, both of which can be highly deceptive. The following methods are acceptable:

1. Place a small quantity of fuel into the container before taking samples from tank or filter drain points. The presence of water will then be revealed by a visible surface of demarcation between the two fluids in the container.
2. Check the drainage samples by chemical means such as water detecting paper or paste, where a change in colour of the detecting medium will give clear indication of the presence of water”.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

__________

1. Flame-out: Flames extinguishing in the combustion chamber of the engine, shutting it down and no longer driving the propeller.
2. Autorotation: 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.

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

At 1845 Western Standard Time (WST) on 16 December 2018, a large (292 m) Cape-size^[1] bulk carrier at Port Hedland anchorage began weighing anchor to board a harbour pilot for berthing to load iron ore. The ship’s bridge team included its master, chief officer, third officer and helmsman. There was a fresh west-north-westerly wind gusting to about 30 knots at times.

A few minutes after 1900 the anchor was aweigh, and by 1909 had been heaved all the way in. At 1912, the master began using the main engine and rudder to turn the ship to port towards the pilot boarding ground. At that time, another large (289 m) bulk carrier was anchored 0.76 of a nautical mile (NM) upwind of the Cape-size bulk carrier on its starboard side (Figure 1).

Figure 1: Cape-size bulk carrier’s engine, rudder and relative position (1912 to 1923)

Source: Ship’s manager (Cape-size bulk carrier).

Note: Indicative diagram is not to scale nor aligned ‘north up’.

By 1917:30, the Cape-size bulk carrier had closed to 0.36 of a NM to the anchored bulk-carrier (indicating that the Cape-size bulk carrier’s average speed in the upwind direction was more than 4 knots). In an attempt to pass astern of the anchored ship, the master stopped the engine and then operated astern propulsion .

The Cape-size bulk carrier’s upwind movement continued, and by 1919 it had closed to within 0.20 of a NM of the anchored ship. The master now concluded that collision was certain so he operated ahead propulsion and used starboard rudder in an unsuccesful attempt to minimise collision damage.

At 1920, the Cape-size bulk carrier’s hull in way of its number 3 starboard water ballast tank collided with the bow of the anchored ship, near its stowed port anchor. The ballast tank was breached with a 12 m x 1 m tear in the shipside (Figure 2). The anchored ship’s port anchor and associated equipment were damaged.

Figure 2: Damage to Cape-size bulk carrier’s hull

Source: Ship’s manager (Cape-size bulk carrier).

After the collision, the master manoeuvred the Cape-size bulk carrier clear and re-anchored the ship. The collision damage rendered the ship unseaworthy and unfit for loading cargo.

The findings of an investigation by the Cape-size bulk carrier’s manager included the following.

• The master’s actions to avoid the collision were inadequate and his ship handling was incorrect.
• The passage plan was inadequate with respect to the transit to the pilot boarding ground, and took no account of weather conditions.
• At no stage did anyone in the bridge team identify, assess or discuss the risk posed by the strong winds.
• There was a failure of bridge team management (BTM),^[2] including no independent checking of decisions, challenge and active participation by the chief officer and third officer who simply followed the master’s orders.

Safety action

The Cape-size bulk carrier’s manager advised that as a result of this occurrence, the following safety actions will be implemented:

• The master is to undertake refresher ship handling training that will include manoeuvring in adverse weather conditions.
• The chief officer and third officer will receive refresher BTM training.
• Shipboard safety management system procedures for passage planning, pilot boarding and adverse weather will be amended to address learnings from this collision.

Safety message

This collision highlights the challenges of handling a large ship in ballast condition when there are strong winds, particularly when there is limited sea room. In this case, the wind rapidly took control of the ship once it was underway because the engine and rudder movements were late. When given, the engine and rudder orders were not appropriate, adequate, decisive and timely, and made recovery difficult.

The accident also shows that in addition to ship handling skills gained through experience and training, carefully planning all stages of a passage is vital to avoid high-risk navigation and to recover from a hazardous situation if one develops.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

__________

1. Dimensions larger than that allowable for transit of the Panama Canal.
2. Bridge team management (BTM) is similar to bridge resource management (BRM), which can be defined as the effective management and use of all appropriate resources, including personnel and equipment, by a ship’s bridge team to complete its voyage safely and efficiently. Shipmasters and mates are required to undertake formal BTM or BRM training.

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

On 27 November 2018, a Piper PA-31 was operating a charter flight with one pilot and three passengers on board to Palm Island, Queensland.

After landing, the nose wheel tyre was punctured by foreign object debris (FOD)^[1] on the runway. The nose wheel began to vibrate resulting in the pilot braking with caution and applying back pressure^[2] to alleviate the pressure on the nose wheel. The rubber on the tyre started to disintegrate and the rim of the wheel dug into the soft asphalt, caused by the extremely hot conditions.

The tyre became caught between the rim and the fork of the nose gear, which acted as a brake and rudder causing the aircraft to veer to the right and off the runway resulting in a nose gear failure. The pilot shut down both engines to reduce the possibility of debris becoming projectiles and to minimise damage to the aircraft before both propellers struck the ground unpowered. 

A screw is suspected to have caused the tyre puncture as nuts and bolts were observed during the runway inspection after the occurrence.

Figure 1: Damage sustained to the aircraft after landing

Source: Operator

Safety message

This occurrence highlights the importance of carrying out regular runway inspections as FOD has the potential to affect aircraft during critical phases of flight. Boeing, in Foreign Object Debris and Damage Prevention, estimate that FOD damage costs the aviation industry $4 billion per year.

All aerodromes are encouraged to have an active FOD management program in place. Aerodrome staff and pilots are reminded to keep an active lookout and retrieve any identified FOD before it becomes a hazard.

Further information about FOD management at aerodromes can be found on the Australian Airports Association website: Foreign object debris.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

__________

1. Foreign object debris: Any object, live or not, located in an inappropriate location in the airport environment that has the capacity to injure airport or air carrier personnel and damage aircraft.
2. Back pressure: The application of back pressure to the yoke to slowly raise the aircraft’s nose and increase its angle of attack.

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

On 21 December 2018, the pilot, and sole occupant of the Ayres Corporation S2R departed Dalby, Queensland to conduct aerial agriculture spraying.

During initial climb, at about 200 ft above ground level, the aircraft did not respond to control inputs to climb further. The pilot turned right to avoid hitting obstructions but found the aircraft was not performing in the way he expected. The pilot attempted to climb by increasing the throttle to maximum and lowering the nose of the aircraft to increase airspeed, but the aircraft was unable to maintain height.

As the aircraft’s airspeed decreased, the pilot experienced wallowing^[1]. The pilot attempted to drop the chemical load to lighten the aircraft’s weight, but the aircraft did not respond. The pilot then lowered the nose of the aircraft to conduct a forced landing. The aircraft entered a stall and subsequently impacted a row of trees resulting in substantial damage and minor injuries to the pilot.

Figure 1: Ayres Corporation S2R post-accident

Source: Chief Pilot

Safety message

This accident highlights the importance of monitoring and checking instruments during flight, to ensure aircraft speed and performance is maintained. As aircraft speed reduces and approaches Vmca^[2], low speed controllability of the aircraft becomes very difficult. Pilots and operators are also reminded of the need to ensure that the aircraft’s weight is within limits and maximum take-off weight to ensure the on-going safety of the aircraft and operations.

The pilot involved in this accident was required to make important decisions in a short period of time, including where to land and how to manage the remaining altitude. Pre-flight self-briefing is an important tool in reinforcing planned emergency actions.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

__________

1. Wallowing - Uncommanded motion about all three axes of an aircraft occurring simultaneously.
2. Vmca - Minimum control speed in the take-off configuration minimum control speed.

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

On 19 January 2019, the pilot of a Piper Aircraft Corp PA-28-161 departed Bankstown, New South Wales (NSW), to conduct a return solo training flight to Taree, NSW. The weather en-route at the time of departure included low cloud and reduced visibility. The adverse weather and amended flight plan options were discussed with the instructor prior to departure.

On the return leg to Bankstown, the pilot observed cloud building along the coast and en-route. When the aircraft reached Anna Bay, 23 km east of Williamtown Aerodrome, NSW, the pilot attempted to descend below cloud to remain visual, but was unsuccessful due to the low cloud coverage resulting in the pilot climbing back to 1,500 ft above mean sea level (AMSL). At this stage, the cloud cover was overcast^[1] with base approximately 600 ft AMSL and tops of 1,500 ft AMSL.

Air traffic control (ATC) contacted the pilot to determine why the aircraft was descending and climbing. The pilot advised ATC that he was trying to get below the cloud but was unable. ATC advised the pilot that further adverse weather was at the destination and provided options to divert to an alternate landing area. The pilot declined the diversion and elected to continue to Bankstown. Shortly after, the pilot asked ATC for further assistance and requested a suitable alternate landing area. ATC advised that Williamtown Aerodrome, NSW was available with favourable weather.

The pilot accepted the diversion and ATC instructed him to track east of Williamtown, over the coast and climb to 2,400 ft. Once over the coast, ATC further instructed the pilot to descend through cloud to 500 ft. ATC further assisted the pilot with instructions to keep wings level, to trust the artificial horizon^[2], not to exceed 1,000 ft per minute rate of descent while in cloud to prevent spatial disorientation and to control a stable descent.

As the aircraft descended through cloud, the pilot became visual over the water at 600 ft AMSL. The pilot then advised ATC that he was out of cloud and visual with ground and water. ATC issued a clearance to track direct to the aerodrome.

Visual Meteorological Conditions (VMC) requirements

Table 1: VMC criteria for aeroplanes below 3,000ft above mean sea level

Class of Airspace	Flight Visibility	Vertical and Horizontal distance from cloud	Conditions
Class G  (Uncontrolled) or within 1,000 ft of ground	5,000M	Clear of cloud and in sight of ground or water	Radio must be carried and used on the appropriate frequency
Class D  (Controlled)	5,000M	600M horizontal 1,000FT vertically above cloud Or 500FT vertically below cloud	ATC may permit operations in weather conditions that do not meet these criteria (Special VFR).

Source: Aeronautical Information Publication (AIP) Australia: ENR 1.2-4 10 November 201

Safety message

Pilots are encouraged to make conservative decisions when considering how forecast weather may affect their flight. If poor weather is encountered en-route, timely and conservative decision making may be critical to ensuring a safe outcome.

VFR^[3] pilots are also encouraged to familiarise themselves with the definition of VMC criteria and carefully consider available options where forecast or actual conditions are such that continued flight in VMC cannot be assured.

Flying with reduced visual cues and Inflight decision making such as in this occurrence remains one of the ATSB’s major safety concerns.

Number 4 in the Avoidable Accident series published by the ATSB titled ‘Accidents involving pilots in Instrument Meteorological Conditions’ lists three key messages for pilots:

• Avoiding deteriorating weather or IMC^[4] requires thorough pre-flight planning, having alternate plans in case of an unexpected deterioration in the weather, and making timely decisions to turn back or divert.
• Pressing on into IMC conditions with no instrument rating carries a significant risk of severe spatial disorientation due to powerful and misleading orientation sensations in the absence of visual cues. Disorientation can affect any pilot, no matter what their level of experience.
• VFR pilots are encouraged to use a ‘personal minimums’ checklist to help control and manage flight risks through identifying risk factors that include marginal weather conditions.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

__________

1. Overcast - Overcast or overcast weather, as defined by the World Meteorological Organization, is the meteorological condition of clouds obscuring at least 95% of the sky.
2. Artificial Horizon - Is a flight instrument that informs the pilot of the aircraft orientation relative to Earth's horizon, and gives an immediate indication of the smallest orientation change.
3. Visual Flight Rules
4. Instrument meteorological conditions (IMC): weather conditions that require pilots to fly primarily by reference to instruments, and therefore under Instrument Flight Rules (IFR), rather than by outside visual reference. Typically, this means flying in cloud or limited visibility.

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

At 1015 Eastern Standard Time on 14 June 2018, a harbour pilot boarded a 180 m general cargo ship, off Newcastle. The ship was to berth at West Basin berth 4 in the port. Another ship, a Dredger, was already berthed there. The general cargo ship was to moor port side alongside the wharf, about 20 m astern of the Dredger.

At 1120, the general cargo ship was approaching berth 4 at minimal speed. The pilot pointed out an orange bollard near the wharf’s edge to the ship’s master (Figure 1). The pilot intended to line up the ship’s navigation bridge (bridge) with this ‘bridge marker’^[1] to position the ship at the berth, clear of the Dredger.

Figure 1: Orange bollard (left hand corner of photo, and generic image – below right)

Source: Pilot & ATSB

Shortly afterwards, the port officer on the wharf called the pilot via radio to advise him that the general cargo ship’s bridge was 20 m ahead of the bridge marker. The pilot was surprised as the orange bollard was still some distance ahead but he immediately ordered full astern on the ship’s main engine. He also ordered the assisting tugs to pull the ship away from the wharf.

However, at 1126, the ship’s bow contacted Dredger’s stern. Soon after, the ship moved clear of the berthed ship, and the pilot manoevered it into the correct position. This position was indicated by an orange cone that the port officer had placed on the wharf (Figure 2).

Figure 2: Orange cone (left hand corner of photo, and generic image – below right)

Source: Pilot & ATSB

The orange cone was located much further back from the wharf’s edge than the bollard, which the pilot mistook for the bridge marker. As the bollard was closer to the Dredger’s stern than the cone, the general cargo ship got further ahead than it should have, and made contact with the berthed ship. The pilot did not see the cone until after the incident.

By 1146, the ship had been securely moored alongside the wharf in the correct position. Visual damage assessments indicated minor damage to both vessels – largely limited to paintwork.

Pilot’s comments

• The orange bollard on the wharf appeared to have been placed there as a bridge marker with nothing to suggest any other purpose (for example, as a hazard marker).
• The orange cone was located unusually distant from the wharf’s edge, where its small size and shadow made identification difficult.
• The only information that alerted the pilot to the situation came from the port officer.

Safety action

As a result of this occurrence, the Port Authority of New South Wales has advised the ATSB that following safety action has been taken.

Traffic control cones used as bridge markers in the port have been fitted with strobe lights, which will be activated for both day and night berthing.

Internal investigation(s) to identify necessary measures to avoid a similar incident.

Safety message

This pilotage incident was the direct result of incorrectly identifying a marker as the bridge marker. Such incidents can be avoided by deploying conspicuous, identical bridge markers that are readily and unmistakably identifiable to the port’s pilots. Therefore, the size, colour and unique features of bridge markers, such as strobe lights, and effective communication between the pilot and person(s) responsible for deploying a marker are important considerations.

 

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

__________

1. A bridge marker on the wharf is used to longitudinally position a ship alongside the wharf by lining up the ship’s bridge with the marker. The marker’s colour, size and other features depend on local practice but ready portability and high visibility is preferred, which makes traffic control cones (witches hats) or similar markers a common choice.

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

On 21 October 2018, an experimental Jabiru J170-D departed Launceston Airport, Tasmania for a local flight. In cruise between 1,500 ft and 2,500 ft above ground level (AGL), a fire began in the cockpit. The pilot, who was the sole occupant on board, conducted an emergency landing into a paddock. The aircraft struck a fence and fire destroyed the aircraft. The pilot sustained serious injuries and received first aid from the landowners until emergency services arrived.

On the morning of the accident, the aircraft was difficult to start. The pilot reported that the aircraft was started using an external portable power supply. This power supply remained connected from inside the cockpit for the duration of the flight, and the pilot reported switching this off after the start. During the flight, the pilot observed the electrical overvoltage alarm both visually and audibly activate on a Dynon D10 engine management system.

It indicated that the electrical system was charging the battery above normal capacity and possibly greater than 15 volts (normal range is 13-13.5v). The pilot had never encountered this problem previously and dismissed the alarm. However, about 5-10 minutes later the fire was observed entering the cockpit.

The pilot began an emergency descent into a paddock as fire began to engulf the cockpit. He opened his door to provide some outside visibility given cockpit windows were no longer transparent, which also assisted with cooling the flames. However, the pilot’s clothes had caught alight. During a high-speed landing, the aircraft bounced and the pilot exited the aircraft prior to the aircraft touching down again. The aircraft collided with a fence and was consumed by fire. (Figure 1).

The pilot found a cattle trough, immersed himself and called for help to a nearby farmhouse. The residents rendered first aid until emergency services arrived.

Figure 1: J170-D consumed by fire

Source: Tasmanian Fire Service, Fire investigation Report Aircraft Fire TFS Incident Number 18033397- Photograph 2, annotated by the ATSB

The Tasmanian Fire Service, Fire Investigation Report^[1] established the area of fire origin on the engine side of the aircraft firewall^[2] in front of the passenger’s feet position and within 400 mm radius of the battery (Figure 2).

Figure 2: J 170-D area of fire origin

Source: Tasmanian Fire Service, Fire investigation Report Aircraft Fire TFS Incident Number 18033397- Photograph 23, annotated by the ATSB, indicating fire origin.

The pilot reported that the engine did not exhibit any abnormal vibration and continued to run until impact with the fence. The pilot stated that the spread of the flames in the cockpit was sustained by a fuel source. This hastened the rapid spread of flames into the cockpit.

The aircraft had about 760 hours total time and had a Deltran 330 Lithium-iron Phosphate battery installed in September 2016, which had recently developed problems. The pilot recalled accidentally flattening the battery a month or two prior by leaving the master switch on. He had experienced problems with the battery since that time. The pilot reported that he used a Deltran trickle charger when the aircraft was not in use. However, the battery was not holding sufficient charge to start the engine consistently. The aircraft then required elevated RPM^[3] in order to get sufficient voltage for the radios to be serviceable during taxi.

The J170-D Pilot’s Operating Handbook indicates that below 2000 RPM the alternator cannot supply sufficient power output to run ancillaries. This power then comes from the battery. Jabiru Service Letter JSL021 further identifies charging system limitations and risks of overvoltage situations. Operating the aircraft with a low voltage battery or one that will not accept electrical system charge may increase this risk.

Thermal runaway in a Lithium-ion battery is a dynamic chemical reaction accompanied by the release of heat. The temperature of the affected cell increases exponentially, triggering nearby cells to also increase their temperature and continue the reaction.

Lithium-ion battery thermal runaway is a known aviation safety hazard and can be initiated by mechanical, thermal of electrical abuse. Over discharge and overcharging of battery cells are two factors that can lead to an electrically induced thermal runaway and subsequent fire.

Safety message

In retrofitting Lithium-ion batteries to experimental aircraft, operators should consider the risks and to be aware of the appropriate charge and discharge requirements for the battery. They may not be suitable for the existing aircraft electrical systems.

Operators should also be aware of the potential risk of damage to Lithium-ion batteries should they be discharged below their minimum cell voltage.

Should a pilot notice any performance change in a fitted Lithium-ion battery, they should take action immediately to remove and replace the battery. This may prevent irreversible damage that may instigate a thermal runaway situation while in use.

In-depth knowledge of individual aircraft systems and regular emergency procedures practice is essential to ensure that pilots provide the most appropriate responses to uncharacteristic warnings or emergencies in flight.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

__________

1. Tasmanian Fire Service, Fire investigation Report Aircraft Fire TFS Incident Number 18033397
2. A wall made of fireproof material, designed to prevent the spread of a fire, as in buildings, aircraft, motor vehicles, etc.
3. Revolutions per minute of engine speed