The ATSB’s investigation into the collision with terrain of a Cessna 206, registration VH-WZX, at Apollo Bay Airfield in Victoria, underlines the importance of pilots executing an early and correctly executed go-around during approach and landing.

On 31 January 2018, the pilot of VH-WZX touched down at Apollo Bay Airfield and then bounced and floated along the runway. The pilot attempted to complete the landing, but the aircraft continued to float and drift right, over the adjacent grass fly-over area, where it possibly bounced for a second time. With one quarter of the runway remaining the aircraft then touched down on the grass and bounced again.

After commencing a late go-around, the pilot did not immediately follow the go-around procedure as directed by the aeroplane flight manual. As a result, the aircraft did not climb as expected and struck the airfield boundary fence and continued flying. After striking the fence, the pilot again deviated from the aircraft manufacturer’s recommended go-around procedure and the aircraft descended and impacted a tree. The pilot then completed a left circuit for the runway and landed safely.

The incident highlights the need for pilots to anticipate, plan and execute early and correctly executed go-arounds.

ATSB Executive Director Nat Nagy says the incident highlights the need for pilots to execute an early go-around as recommended by the aircraft’s manual.

“The best way to avoid a late go-around is to anticipate and plan an early decision point for when to commence a go-around,” Mr Nagy said. “We support the advice of the Federal Aviation Administration, who suggest that if the landing cannot be made in the first third of the runway, you should execute a go-around.”

“In this instance, the go-around was not only late but was not carried out in line with the aircraft’s manual, making it harder for the aircraft to avoid obstacles and increasing the risk of collision.”

“While the outcome of the incident was fairly minor, it could have been much worse,” Mr Nagy said.

Read the final report: Collision with terrain involving Cessna 206, VH-WZX, Apollo Bay, Victoria, on 31 January 2018

For more information on when and how to execute a go-around read the FAA’s Airplane Flying Handbook, Chapter nine Approaches and Landings(Opens in a new tab/window)

The investigation into the fatal accident of a Cessna 172S has resulted in the Bureau issuing safety recommendations to the aircraft and autopilot manufacturers about providing limitations, cautions and warnings for autopilot systems and audible pitch trim movement.

The accident occurred on 8 September 2015, when a Cessna 172S was conducting a solo navigation training flight from Point Cook Airfield in Victoria. GPS data later showed the aircraft was on the third leg of the planned journey, cruising at about 3,000 ft above mean sea level, when it started to descend rapidly. The aircraft impacted rising terrain at about 2,200 ft and was destroyed. The pilot, who was the sole occupant, was fatally injured.

The investigation found that it was likely the pilot had manually manipulated the controls while the autopilot was on and engaged in a vertical mode. As a consequence, the autopilot re-trimmed the aircraft against pilot inputs, inducing a nose-down mistrim situation, which led to a rapid descent. The aircraft’s low operating height above the ground, along with rising terrain in front of the aircraft, would have given the pilot limited time to diagnose, react, and recover before impact. The investigation indicates that the pilot may have been unaware of the exact properties of the autopilot.

ATSB Executive Director, Mr Nat Nagy, said that this accident highlighted a matter of serious concern.

“...if automation is not performing as expected, then the safest option under most circumstances is for them to disengage the system...”

“It is now common for general aviation aircraft to be equipped with advanced avionics and autopilot systems,” Mr Nagy said. “And while these systems can be very useful, it is vitally important that pilots understand how the systems will react in different circumstances.”

After the accident, the flight training organisation conducted flight testing and has emphasised to their students the hazard of manually manipulating the flight controls with the autopilot engaged. They have also updated their operations manual to include warnings about the operation and function of the autopilot system - warnings that are absent in the manufacturer’s documentation.

“This is knowledge that all pilots need to possess,” Mr Nagy said. “Pilots should also be aware that if automation is not performing as expected, then the safest option under most circumstances is for them to disengage the system and fly the aircraft manually.”

The ATSB issued recommendations to the aircraft and autopilot manufacturers, calling for them to provide limitation, cautions, and warnings for autopilots and audible pitch trim movement.

Read the final report: Collision with terrain involving Cessna 172, VH-ZEW, Millbrook, Victoria on 8 September 2015

The ATSB’s report into the partial engine power loss and ditching of a Robinson R44, near Hamilton Island, Queensland, found adequate preparation and post-landing actions by the pilot lead to a positive outcome from an emergency ditching.

On 8 November 2017, passengers of a scenic flight were given a safety briefing advising them to wear their seatbelts and life jackets, which they complied. About 40 minutes into the one-hour flight, the helicopter began to lose engine power. After unsuccessful attempts to increase power, the pilot elected to conduct an autorotation onto the water.

The pilot successfully landed the helicopter on the water, shut down the engine, and applied the rotor brake. The pilot then activated the emergency locator transmitter and instructed passengers to inflate their life jackets and prepare to exit the helicopter, if necessary. The passengers and the pilot, who were uninjured, were rescued by the crew of a local vessel about an hour later.

Transport safety is a shared responsibility.
Operators, pilots and passengers all need to understand and follow safety instructions, procedures and policies.

ATSB Executive Director, Transport Safety Nat Nagy says the incident highlights the importance of pilots conducting a thorough pre-flight safety briefing and for passengers and aircraft to be properly equipped for an emergency situation.

“Transport safety is a shared responsibility,” said Mr Nagy. “Operators, pilots, and passengers all need to understand and follow safety instructions, procedures and policies.”   In this instance the combination of the emergency floatation system, passengers wearing their life jackets and the pilot’s post-landing actions resulted in a positive outcome from a potentially dangerous situation.

“Without the emergency floatation system the risk of the helicopter sinking with the passengers and pilot on board would have been far greater.”

Read the final report: Partial engine power loss and ditching involving Robinson R44, VH-WRR, 49 km N of Hamilton Island Airport, Queensland, on 8 November 2017

The ATSB’s investigation into the collision between a freight train and road-train truck reflects the ongoing concern of safety at level crossings.

The incident occurred on 11 July 2017, as a road-train was proceeding down the Cobb Highway from Broken Hill, New South Wales (NSW) toward Condobolin, NSW. The road-train was hauling two trailers, loaded with 43.7 t of road-base material. The driver knew there was a level crossing ahead, having used it on many occasions over the previous month, including multiple times that very day. The level crossing was equipped with flashing lights, an audible warning device (bell), as well as passive warning signs posted on the road approaching the crossing.

As the road-train negotiated a sweeping right-hand turn before the road straightened towards the level-crossing, the driver saw the flashing lights indicating that a train was approaching. He would later recall that the alignment of the road’s bends and the roadside vegetation meant that he did not see the flashing lights until his vehicle had travelled through the bend and was within 180 m from the crossing.  

The driver started to brake, but then assessed that the road-train might not stop in time, so he accelerated to cross ahead of the train.

It is troubling that this continues to be a problem in Australia.

The train driver saw the road-train accelerate and he sounded the locomotive’s horn. The train consisted of two locomotives and 27 wagons loaded with lead and zinc. About 100 m from the crossing, the train driver made an emergency brake application and activated the ‘emergency in progress’ alarm on the train radio. The train crew then relocated to the floor of the locomotive cab in preparation for a collision.

The train subsequently collided with the rear corner of the last trailer of the road-train, travelling a further 319 m before stopping. The train crew and the driver of the road-train were shaken but otherwise unhurt.

ATSB Executive Director, Transport Safety, Nat Nagy says that collisions at level crossings occur too frequently.

“From July 2016 to June 2017, there were 27 railway crossing collisions between trains and road vehicles,” Mr Nagy said. “That is too many.”

Although motorists are primarily responsible for avoiding a collision with a train at railways crossings, prudent road design and/or advance warning of a train’s presence at railway crossings should be considered as a strategy to lower the risk of road and rail vehicle collisions.

The ATSB report urges road and rail authorities to consider measures to enhance the awareness of motorists approaching railway crossings, especially at location with restricted sighting due to curved approach roads.

“It is troubling that this continues to be a problem in Australia,” Mr Nagy said. “The risk of continuing fatalities or serious injuries is real.”

Read the final report: Level crossing collision between freight train 8426N and road-train truck, Cobb Highway, Ivanhoe, New South Wales, on 11 July 2017

On 13 March, 2017, a Qantas Airways Boeing 737 was travelling to Canberra on a scheduled passenger flight from Perth Airport, Western Australia. There were two flight crew, five cabin crew, and 177 passengers on board.

As the aircraft began descending towards Canberra Airport, it encountered increasing turbulence, and the flight crew switched on the ‘Fasten Seat Belt Sign’, calling for cabin crew members to be seated within one minute of the announcement. The crew began to move towards their seats, securing the cabin as they went.

At 22,000 feet, an abrupt change in the direction of the wind resulted in the aircraft airspeed increasing towards the maximum allowable operating speed.

To prevent an overspeed, the pilot flying applied backpressure on the control column, so as to override the autopilot. This was a common practice for B737 flight crews at Qantas, and the first officer recalled that this was part of initial training for the B737. The expected outcome was that the autopilot would revert to a different mode and raise the aircraft’s nose.

A cabin crew member who had not yet reached her seat felt the cabin floor drop and then quickly come up

In this case, however, the autopilot disengaged, and the aircraft moved abruptly. A cabin crew member who had not yet reached her seat felt the cabin floor drop and then quickly come up. The force of the aircraft’s movement resulted in her fracturing her leg, while a second cabin crew member fell and hit her head on a trolley.

The injured crew member was given first aid and the aircraft landed without further incident. Paramedics met the aircraft to attend to the two injured cabin crew.

The method of intervention by the pilot was understandable, and consistent with previous responses of other flight crew in similar situation. Modification of the autopilot, however, had inadvertently left the aircraft vulnerable to this type of scenario.

Qantas has taken steps to address the dangers that this manoeuvre can create. They have issued a safety information notice, warning of the potential dangers of that approach.

The report also highlights the manufacturer’s preferred use of speedbrakes to prevent overspeed. Boeing has advised that they are considering a revision to the overspeed guidance in the 737 flight crew training manual.

“It’s encouraging to see organisations taking steps to address problems as they emerge,” said Nat Nagy, the ATSB’s Executive Director, Transport Safety. “This method of intervention to prevent overspeed had been used 20 times in the past six years, but this occurrence and the resulting investigation has provided an opportunity to make transport even safer.”

Read the final report: Flight path management occurrence involving Boeing 737, VH-VZZ, near Canberra Airport, Australian Capital Territory, on 13 March 2017

The ATSB’s investigation into a main rotor tip strike involving a Eurocopter AS350-BA VH-PHU, 9 km WNW of St. Leonards (ALA) in Victoria found the pilot did not notice an obstacle encroaching into the helicopter landing site (HLS).

The pilot of the Eurocopter approached the Jack Rabbit Vineyard HLS (a tennis court) on 4 July 2017. This was the first time the pilot had used the site. During the approach the pilot identified the key boundaries of the site, including a brick wall at its southern end, but did not notice vegetation intruding into the site.  

Believing that another helicopter was moving into the site, the pilot slowly hover-taxied the helicopter towards the south-west corner of the site. The tips of the helicopter’s main rotor blades struck the vegetation. The pilot was able to safety land and reposition clear of the obstacle. The incident resulted in damage to all three main rotor tips.

All pilots, no matter how experienced, are not immune to errors and experience alone will not protect them from an accident.

ATSB Executive Director Transport Safety Nat Nagy says the incident reinforced the need for pilots to have strong situational awareness when flying near obstacles.

“Strong situational awareness is critical to maintaining aircraft safety, especially when flying in new and confined locations,” Mr Nagy said. “To get a good understanding of a landing site, pilots are encouraged to do a 360-degree reconnaissance.”

“In this instance, the pilot did an abbreviated reconnaissance and didn’t notice an obstacle that needed to be avoided.”

The ATSB investigation found this choice of reconnaissance may have been the result of the pilot’s over-confidence in their pre-planning and flying ability.

“All pilots, no matter how experienced, are not immune to errors and experience alone will not protect them from an accident,” Mr Nagy said.

For insights into how accidents can happen to experienced pilots, download a copy of the ATSB publication, Avoidable Accidents No.6 – Experience won’t always save you: Pilot experience is not always a protection against an accident, from the ATSB website.

Read the final report: Main rotor tip strike involving Eurocopter AS350-BA, VH-PHU, 9 km west-north-west of St. Leonards (ALA), Victoria, on 4 July 2017

The ATSB’s investigation into foreign object damage involving an Airbus A320, VH-VGY at Auckland International Airport on 27 October 2017 found the aircraft’s right engine was damaged by metal debris from a clipboard left in the engine cowling.

After the loading of VH-VGY, the clipboard was left on the right engine cowling to protect it from the weather, with the intent of it being collected later. This did not happen. The presence of the clipboard was noticed during a ‘duty of care’ walk around but not reported.

ATSB Executive Director Transport Safety Nat Nagy says the incident highlights the need for everyone operating near the aircraft to take ownership of reporting foreign objects.

It is easy to think that someone else will report or remove a foreign object but that kind of thinking usually just increases the risk that it won’t get done.

“It is easy to think that someone else will report or remove a foreign object, but that kind of thinking usually just increases the risk that it won’t get done.” Mr Nagy said.

In this instance, staff recalled the need to collect the clipboard as VH-VGY was taxiing. Staff returned to where the aircraft was loaded, saw paper debris on the ground, and realised it had been left in the engine.

After the flight crew were notified, they checked their engine instruments and saw no abnormal indications. However, upon learning that sheared metal had also been found, the aircraft returned to Auckland. An engineering inspection found paper throughout the engine and minor damage to the fan blade and attrition liner.

Both Jetstar and the ground handling operator, Aerocare, have taken steps to educate staff of their reporting responsibilities around foreign objects. Jetstar has also updated their aircraft dispatch procedures to provide more detailed information about aircraft checks and responsibilities.

Read the final report: Foreign object damage involving Airbus A320, VH-VGY, Auckland International Airport, New Zealand, on 27 October 2017

The ATSB’s investigation into a collision with terrain of an amateur-built Sling 4 aircraft at Caloundra aerodrome, in Queensland, found that due the use of incorrect weight and balance data, the flight was conducted with the centre of gravity aft of its rear limit.

Before its flight on the morning of 12 August 2017, the pilot used the average or standard weights of each occupant to calculate the aircraft’s weight and balance with its electronic flight instrument system.

ATSB Executive Director Transport Safety Nat Nagy says that to reduce the risk of overloading the Civil Aviation Safety Authority recommends that load calculations for aircraft with less than seven seats should be based on the actual weight of occupants and baggage rather than standard or average weights.

Using actual weights for the load calculations would have prevented it operating with its centre of gravity aft of its rear limit.

“Using actual weights for the load calculations of the Sling 4 would have prevented it operating with its centre of gravity aft of its rear limit,” Mr Nagy said. “Operating like this meant it was less stable and more susceptible to an aerodynamic stall and harder to recover if a stall occurred.”

While descending, the Sling 4 deviated from its desired flight path. Attempts to continue the approach by manoeuvring the aircraft at low level and speed coupled with its loading outside of the permissible centre of gravity range reduced the remaining margins of controllable flight. 

The aircraft stalled and entered an incipient spin. Recovery from the stall was not possible and the aircraft collided with terrain. The fuselage fractured at the engine firewall and the engine was pushed rearward into the cabin. The aircraft was destroyed. The pilot and three passengers suffered serious injuries.

Further information: Guidance on the use of standard passenger and baggage weights for the calculation of aircraft weight and balance is available in the Civil Aviation Safety Authority’s advisory publication CAAP 235-1(1) Standard passenger and baggage weights(Opens in a new tab/window). Pilots can also refer to the United States Federal Aviation Administration publication Pilot’s Handbook of Aeronautical Knowledge Chapter ten, Weight and Balance(Opens in a new tab/window) for advice on correctly calculating aircraft weight and balance.

Read the final report: Collision with terrain involving The Airplane Factory Sling 4, VH-BEG, Caloundra Aerodrome, Queensland, on 12 August 2017

The ATSB’s investigation into the fuel exhaustion and forced landing of a Piper PA-28, registered VH-BDB (BDB), near Bankstown Airport, New South Wales, highlights the need for effective fuel management to avoid fuel starvation.

The accident occurred on 19 September 2017, when despite having enough fuel on board, the Piper aircraft had a loss of engine power that resulted in a forced landing, 15 km west-south-west of the airport. The loss of engine power was found to be the result of fuel starvation from the selection of a fuel tank with insufficient fuel to complete the flight.

ATSB Executive Director Transport Safety Nat Nagy says that accidents involving fuel mismanagement are an ongoing aviation safety concern.

“Each year, we receive more than 20 reports of fuel exhaustion or starvation,” Mr Nagy said.

You need to understand how the fuel system works on your aircraft, know how much fuel you have in each tank, and make sure you have the appropriate tank selected at all times.

In this occurrence, the pilot of BDB conducted a pre-flight inspection and believed the aircraft had full fuel on board and as the flight was only for 30-40 minutes did not intend to change the fuel tank selector during the flight.

As the aircraft returned to Bankstown and approached waypoint 2RN, the pilot noticed the engine was fluctuating. The pilot selected the electric fuel pump on, but the engine fluctuations became worse. The pilot then performed the engine failure immediate checks, but failed to change fuel tanks, and then carried out a forced landing. The pilot received minor injuries. The aircraft was substantially damaged.

Fuel exhaustion and starvation can occur during any phase of flight.  ATSB data shows that most reported occurrences have been in the cruise or in the descent, approach and landing phases of flight.

“You need to understand how the fuel system works on your aircraft, know how much fuel you have in each tank, and make sure you have the appropriate tank selected at all times,” Mr Nagy said. ‘To reduce the risk of a fuel starvation event when on descent, selecting the appropriate fuel tank during the pre-descent checks will avoid having to manage this during the higher workload period during approach to land.”

For information and procedures to avoid fuel starvation or exhaustion are available in the ATSB’s booklet Avoidable Accidents No.5 – Starved and exhausted: Fuel Management and aviation accidents(Opens in a new tab/window) as well as the Civil Aviation Safety Authority’s Civil Aviation Advisory Publication 234-1: Guidelines for aircraft fuel requirements.(Opens in a new tab/window)

Read the final report: Fuel starvation and forced landing involving Piper PA-28, VH-BDB, 15 km west-south-west of Bankstown Airport, New South Wales, on 19 September 2017

At 47 minutes past midnight, on 15 July 2017, the Spirit of Queensland tilt train was passing through Rockhampton on its way to Brisbane. Its route would take it through the intersection of Denison and William Streets, over a level crossing. The level crossing was a passive-type, with no active devices such as bells or flashing lights. Instead, there were posted signs alerting road drivers to the existence of the level crossing and the need to take care.

Five years earlier, a train had collided with a road vehicle at that intersection, and Queensland Rail and the Rockhampton Region Council had taken steps to resolve some minor issues with the sighting distance and signage.

Now, as the Spirit of Queensland approached the intersection, both of the train’s drivers identified that the intersection and its approaches were clear.

When the train crossed the intersection, however, they both heard a loud bang and there was jolt to the power car. The operating driver immediately applied the brakes and the train stopped about 40 metres later.

Upon alighting from the train, the driver found that the train had struck a road vehicle, a white Toyota Camry carrying four people inside. The car had driven in front of the train, and had been immediately struck on the driver’s side, causing it to spin and collide with the right-hand side of the train in the direction of travel.

Railway level crossing accidents have the potential to be catastrophic.

The three passengers of the car were treated for non-life-threatening injuries. The driver of the car and both train drivers were tested for alcohol and drugs. All tests returned zero readings.

Queensland Rail’s subsequent assessment of the site revealed no issues with sighting distance, signage, or design of the crossing.

According to the driver of the car, the car’s windows were open at the time of the incident, however, its occupants were actively engaged in conversation and none of them heard the train’s horn. The driver stated that the vehicle was slowed almost to a stop as it approached the intersection before accelerating to cross it. Neither the driver nor the passengers had noticed the train until immediately before the collision.

This incident is a reminder that all road vehicle drivers using railway level crossings equipped with passive controls need to be vigilant, observe road-warning signs, obey road rules and look out for trains.

ATSB Executive Director of Transport Safety Mr Nat Nagy said this was part of a familiar pattern in transport safety.

“Unfortunately, the ATSB has investigated a number of similar occurrences,” Mr Nagy said. “Last year alone, we initiated four investigations relating to level crossings. Thankfully, no one was killed this time, but that is not always the case.

“Railway level crossing accidents have the potential to be catastrophic. Taking the time to check and ensure that it’s absolutely safe to cross can make all the difference.”

Read the final report: Level crossing collision between Spirit of Queensland and a road vehicle, at Rockhampton, Queensland, on 15 July 2017