Key points:

• R22 pilot conducted forced landing after sudden loss of engine power during low-level mustering operations
• Examination found damage to the engine’s number-four cylinder intake valve led to reduced engine performance
• Occurrence illustrates the potential seriousness of unexpected yaw and reduced engine performance during flight

A Robinson R22 helicopter pilot had to conduct a forced landing after a sudden loss of engine power due to damage to an engine cylinder intake valve, an Australian Transport Safety Bureau investigation has found.

On 11 January 2022, R22 VH-VHE was being used to conduct mustering operations south-west of Mitchell, in Queensland’s central south.

“During the second mustering flight of the day, the pilot reported hearing a pop and a crack, and experiencing significant uncommanded yaw, and abnormal vibration, resulting in a forced landing,” ATSB Director Transport Safety Stuart Macleod said.

Examination of the engine by a maintenance organisation, and further examination at the ATSB’s technical facilities in Canberra, confirmed that damage to the engine’s number-four cylinder intake valve had allowed the fuel and air mixture, and exhaust gases, into the air induction system.

“This resulted in the degraded engine performance and forced landing of the helicopter,” Mr Macleod said.

Notably, prior to the incident, neither the pilot nor the maintenance organisation observed any indications of the progressing damage to the intake valve, including during a successful compression test 17.6 flight hours prior to the incident.

“While not required, a borescope inspection may increase the likelihood of detecting valve damage that can lead to degraded engine performance,” Mr Macleod noted.

VH-VHE’s engine had been overhauled in August 2021 – six months prior to the incident – and the pilot stated that the engine seemed underpowered following the overhaul.

“In piston engine helicopters, unexpected yaw and reduced engine performance may be symptomatic of developing engine intake valve damage,” Mr Macleod said.

“If this condition remains unattended, it can lead to an increased risk of induction backfire events and significant loss of engine power.”

Mr Macleod added there is an opportunity to improve understanding of engine issues with better quality data.

“Maintenance organisations are therefore encouraged to follow the Civil Aviation Safety Authority recommendation for borescope inspections of valves and report any defects, or nil-defect findings.”

The ATSB’s report also notes that, for reasons that could not be determined, the tail rotor drive shaft fractured as a result of torsional overstress during the incident.

In addition, an unapproved modification was present on the leading edge of the tail rotor blades, although this probably had no influence on the occurrence.

Read the final report: Engine power loss and forced landing involving Robinson R22 Beta, VH-VHE, 130 km south-west of Mitchell, Queensland, on 11 January 2022

The Australian Transport Safety Bureau and Queensland’s Department of Transport and Main Roads have renewed their agreement that sees the ATSB conduct no blame transport safety investigations into rail accidents and incidents in Australia’s second largest state.

ATSB Chief Commissioner Angus Mitchell and TMR Director-General Neil Scales signed a new two-year funding agreement at TMR’s Brisbane headquarters recently, extending the partnership between Queensland and the national rail transport safety investigator through to 30 June 2024.

“ATSB investigations of accidents and incidents on state rail networks is funded by state governments,” Mr Mitchell said.

“The extension of this agreement means the ATSB can continue performing its vital work, which improves safety for Queensland’s rail transport workers and travelling public.”

“The safety of rail safety workers, rail passengers and the general public is paramount. The ongoing relationship with the ATSB demonstrates the importance placed on rail safety in Queensland,” agreed Mr Scales.

Under the current agreement, which began in 2017, the ATSB has conducted over two dozen investigations into rail incidents in Queensland, many of which have identified safety issues for consideration.

ATSB investigations are purely aimed at determining factors which led to an accident or incident so that safety lessons can be learned, and do not lay blame, which encourages the free flow of information during the investigation process, Mr Mitchell explained.

“The identification of safety issues as part of ATSB investigations allows operators and relevant parties to take safety action to address them to help prevent similar accidents and incidents in the future,” Mr Mitchell said.

“I am confident, thanks to this on-going funding arrangement with the State Government, that ATSB investigations will continue to lead to improved rail transport safety for Queenslanders.”

Key points:

• Preliminary report - the investigation into the accident is continuing
• A wedge-tailed eagle bird carcass was located near the accident site
• No pre-accident defects were identified with flight controls, aircraft structure or the engine

A wedge-tailed eagle bird carcass was located near the accident site of Bell LongRanger helicopter which experienced an in-flight break-up near Maroota, New South Wales on 9 July 2022, according to an Australian Transport Safety Bureau preliminary report.

The report details factual information from the early evidence collection phase of the investigation into the accident, and does not contain analysis or findings, which will be detailed in the investigation’s final report.

The Bell 206L1 LongRanger, registered VH-ZMF, had departed a private helipad in Cattai. The helicopter then climbed to about 700 ft above mean sea level and tracked north towards the planned destination in St Albans.

A witness to the south of Dargle Ridge recalled seeing a helicopter moments before the accident, flying straight and level towards the north, and that weather conditions were good, with clear skies and light winds.

“Several witnesses described then seeing the helicopter enter a rapid banking turn to the right while pitching up,” ATSB Chief Commissioner Angus Mitchell said.

“They heard several rotor beats change tone before a final louder noise.”

Witnesses then recalled the helicopter pitching and rolling while descending, with one witness describing separation of the main rotor blades from the helicopter.

Smoke was then observed rising from the area where the helicopter descended. The helicopter was subsequently found to have been destroyed by a post-impact fire, with the pilot sustaining fatal injuries.

“Site and wreckage examination undertaken by the ATSB determined that the vertical stabiliser, aft section of the tail boom, tail rotor and tail rotor gearbox were severed in flight and found separate to the main wreckage,” Mr Mitchell explained.

“No pre-accident defects were identified with flight controls, aircraft structure or the engine.”

A bird carcass was found to the south-west of the main wreckage site, near a section of rotor tip.

The carcass, the main rotor blade tip and a section of impacted tail boom were recovered from the site for further analysis.

“Testing on the bird carcass and biological residue found on external helicopter surfaces at the main wreckage site identified both as Aquila audax – commonly known as a wedge-tailed eagle,” Mr Mitchell said.

The ATSB’s investigation into the accident is continuing.

“With this evidence indicating a bird strike occurred prior to an in-flight break-up, the investigation moving forward will aim to determine the full sequence of events, and potential safety learnings from this accident,” Mr Mitchell said.

A final report, which will include analysis and findings, 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,” Mr Mitchell said.

Read the preliminary report: In-flight break-up involving a Bell 206L-1 LongRanger, registered VH-ZMF, near Maroota, NSW, on 9 July 2022

The Australian Transport Safety Bureau anticipates amendments to the Transport Safety Investigations Regulations (TSI Regulations), which detail the requirements for reporting transport accidents and incidents to the ATSB, will take effect on 1 January 2023. 

“The TSI Regulations set out the ATSB’s safety occurrence reporting scheme and prescribes what occurrences must be reported to the ATSB, the ‘responsible persons’ who are required to make a report, and the particulars to be included in a report,” said ATSB Chief Commissioner Angus Mitchell. 

For the marine industry, changes to the Regulations primarily relate to the new requirement that marine pilotage providers and vessel traffic service authorities are prescribed as “responsible persons” who will now be required to report transport safety occurrences. 

“This is to cover occurrences which would otherwise not be reported because a ship leaves port and no other relevant entity with knowledge of the occurrence would be in a position to report to the ATSB,” Mr Mitchell explained.  

For the marine industry – AMSA is a nominated official to receive occurrence reports from responsible persons, which are then transmitted to the ATSB. 

“Capturing additional reporting from pilotage providers and vessel traffic service authorities will establish a more accurate dataset for safety analysis conducted by the ATSB.”  

In consultations with industry and AMSA, some pilotage providers and vessel traffic service authorities already voluntarily submit reporting to AMSA.  

The amendments have now been approved by the Minister for Infrastructure, Transport, Regional Development & Local Government, and have been proposed to the Executive Council for endorsement in coming weeks. The amended Regulations and new reporting requirements would take effect from 1 January 2023.  

“Reporting is a simple and quick process,” Mr Mitchell concluded.  

“Nonetheless we do recognise the marine industry has been through a period of considerable change and disruption in recent years and do stress that our approach to implementing these amended regulations is to focus on education and encouraging better reporting practices over an extended period, with less emphasis placed on compliance particularly for industry participants who may not be fully across the new requirements. 

“Ultimately all of industry benefits from an open and trusted and marine occurrence reporting framework.” 

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Amendments to the Transport Safety Investigations Regulations (TSI Regulations), which detail the requirements for reporting transport accidents and incidents to the ATSB, will take effect on 1 January 2023. 

“The TSI Regulations set out the ATSB’s safety occurrence reporting scheme and prescribes what occurrences must be reported to the ATSB, the ‘responsible persons’ who are required to make a report, and the particulars to be included in a report,” said ATSB Chief Commissioner Angus Mitchell. 

The changes predominantly relate to the aviation industry. 

“For aviation there are two key changes being introduced in the amended regulations – the creation of four categories of aircraft operations, each with different reporting requirements, and new requirements for sport aviation bodies to report accidents and incidents to the ATSB,” Mr Mitchell explained. 

The four categories comprise Category A (passenger transport), Category B (commercial non-passenger, including medium to large RPA), Category C (non-commercial) aircraft operation, and Category D (small non-excluded RPA and certain uncrewed balloons) aircraft operation.  

“Higher categories, in particular passenger-carrying and commercial operations, will have a greater reporting focus due to the greater public safety benefit that could be derived,” said Mr Mitchell.  

“Non-commercial aircraft operations and uncrewed RPA and balloons will have lower reporting requirements.” 

The Regulations define occurrences that must be reported to the ATSB as “immediately reportable”, which must be reported by telephone as soon as reasonably practical, and “routine reportable” matters, which can be notified to the ATSB by a written report within 72 hours. 

“Changes to the regulations ensure immediately reportable matters are those more likely to be considered for investigation by the ATSB, while reducing the reporting requirements on industry for those matters the ATSB is less likely to consider for investigation,” Mr Mitchell explained. 

Other changes to the Regulations include aligning aircraft operation categories and definitions with CASA flight operations rules introduced in December 2021, and aligning definitions of aircraft accident, serious aircraft incident, aircraft incident, fatal injury and serious injury with International Civil Aviation Organization definitions 

“Changes to the regulations also simplify reporting requirements for industry by removing prescriptive lists of individual kinds of occurrences and defining these concepts more broadly.”  

Reporting will be based on more general concepts including accidents, serious incidents, incidents, loss of separation and declaration of emergency. Guidance on the ATSB website and to be provided in the Aeronautical Information Publication details comprehensive examples of type of occurrences that fit into each. 

The ATSB consulted extensively with industry on the proposed changes over a five-week timeframe between January and March 2022. Feedback received during that process was largely positive, and helped shape the final Regulations package. 

The amended Regulations and new reporting requirements will take effect from 1 January 2023.  

“Reporting to the ATSB is a simple and quick process,” Mr Mitchell concluded.  

The ATSB is also updating the reporting forms on the ATSB website to make reporting even easier. 

“Nonetheless we do recognise the aviation industry has been through a period of considerable change and disruption in recent years and do stress that our approach to implementing these amended regulations is focusing on education and encouraging better reporting practices over an extended period, with less emphasis placed on compliance particularly for industry participants who may not be fully across the new requirements.” 

Aside from being the basis for starting safety investigations, all occurrences reported to the ATSB are maintained in Australia’s official aviation occurrence database and used for safety research and analysis.  

“Ultimately all of aviation benefits from an open and trusted aviation occurrence reporting framework.” 

Click here for more information.

A United Nations Day of Significance, World Maritime Day 2022 is calling on the maritime community to have a conversation about the transition of the sector to a greener and more sustainable future.  

This World Maritime Day(Opens in a new tab/window), the Australian Transport Safety Bureau (ATSB) is highlighting the importance of safe and effective container stowage planning to prevent container loss at sea and ocean pollution.  

“The ATSB is an advocate for the safe carriage of containers and for the prevention of their loss at sea through operator compliance of their ship’s Cargo Securing Manual,” ATSB Chief Commissioner Angus Mitchell said. 

“In addition to posing a navigational hazard, lost shipping containers are a significant environmental hazard in the marine environment.” 

A single empty container lost at sea can release iron oxide as it rusts, as well as synthetic polymers and heavy metals from the breakdown of its insulation foam and protective paints. 

The ATSB conducts ‘no blame’ safety investigations into selected maritime incidents and accidents in Australian waters, carried out in conformity with international treaties and instruments to improve maritime safety for all seafarers. 

In 2018, the ATSB conducted an investigation into the loss of containers overboard involving the Liberian-flagged cargo ship YM Efficiency, which occurred 16 NM east-south-east of Newcastle, New South Wales.  

YM Efficiency was en route to Sydney, steaming slowly into strong gale force winds and very rough seas off Newcastle when it rolled suddenly. The ship lost 81 containers overboard and sustained structural damage to its lashing bridges, superstructure, and accommodation ladder.

Over 1,000 tonnes of pollution, including plastics, furniture, tyres, and paper products washed up along 400 kilometres of shoreline with more than 720 tonnes of waste recovered from the waters off the Hunter Coast as a result of the incident.  

The investigation found that the forces generated during the sudden, heavy rolling placed excessive stresses on containers stowed aft of the ship’s accommodation resulting in the structural failure of containers and components of the lashing system, leading to the loss of the containers.  

The investigation also found the weights and distribution of containers in the affected bays meant that the calculated forces exceeded the allowable force limits as defined in the ship’s Cargo Securing Manual (CSM). 

“The ship’s cargo-planning process ashore did not allow for the checking of the proposed container stowage plan’s compliance with the stowage and lashing forces requirements of the ship's CMS,” Mr Mitchell said.  

“This left limited time for the ship’s crew to make amendments without unduly impacting commercial operations and created a reliance on shipboard checks during a late stage of the loading operation.”  

Mr Mitchell noted that despite the checking of stowage plans for compliance with a ship's CMS – now often achieved with loading computer systems that provide some process efficiencies – the scale and pace of modern container ship operations often means ships officers are asked to check, amend or approve proposed stowage plans at late stages in a loading operation. 

“This operational reality reinforces that the planning process ashore is the best opportunity to take all practical measures to ensure that the proposed stowage plan presented to ships officers complies with the CSM and is as safe as reasonably practicable. 

“Weather forecasting, routing and good navigational practices in adverse weather all play a part in minimising the risk of injuries to crew and damage to ship, cargo and environment.  

“However, safe and effective container stowage planning remains the primary control measure in managing the risks involved in carrying containers by sea.” 

Read the ATSB investigation report: MO-2018-008 Loss of containers overboard involving YM Efficiency, 16 NM east-south-east of Newcastle, New South Wales, on 1 June 2018 

Read more about World Maritime Day(Opens in a new tab/window)