On 11 November 2016, a Cessna 208B aircraft was on a re-familiarisation training flight with an instructor and trainee pilot on-board.

After take-off, at an altitude of about 500 ft, the instructor noted the climb speed reducing while the trainee continued to maintain the nose attitude for best angle of climb. At the same time, the instructor heard the engine lose power and a thin film of fuel partially obscured the windscreen.

As the airspeed reduced to 60 kt, the instructor took control and identified a suitable area for a forced landing and began a left turn at the target glide speed of 85 kt. At the completion of the turn, they selected 30 degrees of flaps to provide a short climb, which allowed the aircraft to clear two hangars and an area of trees.

After clearing the hangars and trees, the aircraft landed without further incident.

A post-accident examination of the engine found the number eight fuel nozzle locking plate missing—probably not reinstalled when fuel transfer tubes and nozzles were installed after replacement.

The missing locking plate allowed the fuel transfer tube to slowly migrate out of the nozzle adaptor over the 86 hours since the maintenance occurred. Fuel escaped, leading to engine power loss in flight.

Australian Transport Safety Bureau Chief Commissioner Greg Hood says the incident serves to underline the importance of ensuring all maintenance is completed entirely and correctly.

“The locking plate was not installed during scheduled maintenance, and yet the fuel leak did not develop for a further 86 flight hours,” he said. “This demonstrates how the effects of incomplete maintenance can take a long period of time to manifest.”

Read the final report: Engine failure and forced landing involving Cessna 208, VH-TYV, Darwin Airport, Northern Territory, on 11 November 2016

Effective use of Crew Resource Management procedures by a Fairchild SA227 flight crew helped them safely deliver 13 passengers from Armidale, NSW, to Brisbane, Queensland, after a mid-flight engine failure.

At 7.55 am on 12 October 2016, the aircraft was about 170 km south of Brisbane when it suddenly yawed to the right.

The flight crew noted that all right engine indications were normal except for a low torque reading and low fuel flow. They confirmed that the right engine was not delivering power, shut it down and feathered the right propeller.

Air traffic control gave them a direct track to Brisbane Airport. After completing their normal and single engine landing checklist, the Fairchild landed at Brisbane Airport runway 19 without further incident.

Australian Transport Safety Bureau Chief Commissioner Greg Hood says that, following the aircraft yaw, the flight crew actively employed their crew resource management procedures to identify and confirm the engine fault and shut it down.

“The use of these procedures reduced the risk of an incorrect diagnosis of the fault, or activation of the incorrect engine controls during shut down,” Mr Hood said.

The ATSB investigation found that the failure of a retainer ring that led to an engine gearbox malfunction, was within the required gearbox inspection intervals and without prior warning of an impending failure.

As a result of this occurrence and subsequent to an update by the engine manufacturer to the engine manufacturer’s service bulletin, the aircraft operator has advised the ATSB that they have reduced their engine oil testing interval from 150 hours to 100 hours.

Retainer ring

Read the final report: Engine failure involving Fairchild SA227, VH-VEU, 170 km south of Brisbane, Queensland, on 12 October 2016

Education and training helped the crew of a Fokker F28 MK 100 manage two emergencies, including a hydraulic failure that compromised nose-wheel steering.

The crew’s response ultimately ensured the safe landing, taxiing and subsequent evacuation of 97 passengers, three cabin crew and two flight crew on a Newman to Perth flight on 23 September 2016.

About 550 km north of Perth, the flight crew were alerted to the issue resulting from the hydraulic failure. They arranged for assistance to be available at Perth airport to tow the aircraft from the runway to the gate.

The flight crew notified Air Traffic Control of the fault and discussed the implications of the failure. Without nose-wheel steering, they planned to land the aircraft on runway 21 at Perth Airport and roll through to the end of the runway, where a pre-positioned tug would tow it to the allocated gate for passenger disembarkation.

Rather than use the engines for electrical power and air-conditioning during the aircraft tow, the captain elected to start the auxiliary power unit (APU) during the approach. The APU would then supply air for the air-conditioning system after landing and electrical power after the engines were shut down.

The aircraft landed without further incident and rolled through to the end of runway 21.

Despite the pre-arrangement, there was no tug waiting for the aircraft, so the flight crew used differential braking to turn the aircraft off the runway and onto the taxiway before stopping.

At this point the cabin crew manager reported to the captain that fumes were present in the cabin. An emergency evacuation was conducted, during which three passengers received minor injuries.

Australian Transport Safety Bureau Chief Commissioner Greg Hood says the incident highlights the importance of training and procedures, and the need for organisations to educate their workforce about safety incidents.

“The flight crew were confronted with consecutive emergencies,” Mr Hood said. “They responded to each situation in accordance with their training and procedures, which resulted in everyone safely evacuating the aircraft with only minor injuries reported.”

Read the final report: Emergency evacuation involving Fokker F28, VH-NHY, Perth Airport, Western Australia, on 23 September 2016

Effective simulator training and robust failure management procedures proved invaluable to the passengers and crew of an early-morning Regional Express flight from Ballina, NSW, on 23 August 2016.

The SAAB 340 aircraft, comprising three crew and 22 passengers, suffered an engine failure shortly after take-off.

As the landing gear was retracting, the crew heard loud bangs and the left engine operation degraded, reducing the climb performance. Passengers alerted crew to flames coming from the affected engine.

Based on noises and engine instrument indications, the crew identified the issue as a compressor stall, and carried out the failure management procedure. The left engine was shut down and the first officer advised ATC that they had one engine inoperative.

The flight returned safely to Ballina, with no injuries to crew or passengers and no damage to the aircraft.

The two members of the flight crew said their simulator training, dealing with compressor stalls and one-engine-inoperative scenarios, had helped manage the situation. The captain also said the aircraft was easier to handle than the simulator.

Faced with an abnormal scenario, thanks to their training and robust procedures, the crew was able to manage a challenging situation efficiently and safely.

Read the final report: Engine in-flight shutdown involving Saab 340, VH-ZRJ, 19 km north of Ballina/Byron Gateway Airport, New South Wales, on 23 August 2016

From flight attendant to human factors safety investigator, Indonesia’s Ucu Suherman has already helped halve the death toll resulting from one of her country’s most popular events.

Ucu is in Australia to attend an Australian Transport Safety Bureau’s Human Factors for Transport Safety Investigators course in Canberra and a psychology symposium in Adelaide.

She is proud of her work in helping to make the Lebaran holiday period safer for Indonesians.

Lebaran is one of Indonesia’s major national holidays, lasting several days after the fasting ritual of Ramadhan. More than 30 million people travel—mostly by road—to Jakarta, congesting the city’s vehicular arteries.

Ucu, 37, says the Indonesian Government and its National Transportation Safety Committee (NTSC), developed messages focusing on driver fatigue to reduce the injury and death toll.

“In 2014 there were 3888 accidents with 714 deaths and 1939 people seriously injured,” Ucu said.

“After our campaign this year using messages about fatigue, the number of accidents was 1947. The death toll was reduced to 366 with just 634 serious injuries. This was a big improvement.”

After graduating from university in 2002 with a psychology degree, Ucu started working as a flight attendant for Merpati Nusantara Airlines. She was soon asked to join the safety division as a human factors officer. A year later Ucu was invited to conduct training for flight attendants.

“This was a very busy time for me but I enjoyed the training work very much,” she said.

Keen to further her experience, Ucu took up a position with Lion Air Group as flight attendant instructor, where she worked for five years before being asked to become the safety management systems manager.

An opportunity to join the NTSC in 2016 as a safety investigator was too good to refuse. Ucu’s work at NTSC includes not only Human Factors input to investigations, but also training for other NTSC staff and Indonesian aviation industry personnel.

“I have worked at the NTSC for only seven months but I love the human element of this work,” she said. “Seeing what happens beyond the system—the human factors perspective is very interesting.”

One of only three female safety investigators at the NTSC, Ucu is in Australia to benefit from the Australian government Indonesia Transport Safety Assistance Package (ITSAP). Her colleague Apib Prayogi was in Canberra in September.

The ATSB's contribution to ITSAP is to deliver training and support for investigators from the NTSC to enhance transportation safety for the people of Indonesia and Australian travellers to Indonesia.

Ucu had an opportunity to experience a uniquely Australian experience while here—the Melbourne Cup. But the highlight of her day was eating lamingtons and pavlova. “I love it,” she said.

Aircraft passengers are being urged to take extra care of their electronic devices onboard aircraft following two separate safety incidents involving crushed smartphones on 21 October 2016.

In both instances, the business-class passengers inadvertently crushed their phones while moving their seats, after their devices were accidently dropped down the side of the seat.

The first incident occurred when the aircraft was descending into London. As the cabin crew was serving the passenger, the seat was moved electronically, crushing the passenger’s smartphone and resulting in the phone emitting smoke.

The phone had been on charge at the time. Once the charging cable was removed, the smoke started to dissipate. The phone was placed in a metal bin and covered with water.

In a second incident, while flying to Sydney, a passenger asked a cabin crew member to help retrieve his phone from the seat after it got stuck there while he was sleeping.

The phone was damaged during the retrieval process, and it started to make intermittent bright flashes and a hissing noise.

The crew quickly placed the phone in a steel jug of water with no injury or damage to the aircraft.

The operator is undertaking a range of safety actions to prevent future occurrences. This includes changes to safety briefings reminding passengers not to move their seats when their devices have been lost and to ask a crew member to recover the phone.

These two incidents follow other similar occurrences investigated by the ATSB:

• On 21 June 2016, a passenger’s personal electronic device caught fire while flying from Los Angeles to New York in the US.
• On 15 May 2016, cabin crew located a passenger’s electronic device tightly wedged in the seat mechanism after it emitted smoke during a flight from Sydney, Australia to Dallas in the US.

In all these incidents, the cabin crew provided an effective response to an emergency situation.

Passengers should be reminded of the following:

• Phones should be kept in an approved stowage, unless in use
• Passengers should locate their phone before moving powered seats
• In the event that a passenger cannot locate their phone, they should refrain from moving their seat and immediately contact a cabin crew member
• Passengers should always follow the directions of cabin crew.

The Australian Transport Safety Bureau (ATSB) will boost its investigation capability with the imminent deployment of a new remotely piloted aerial system (or drone).

The use of drones in safety investigations has the potential to significantly reduce costs and improve investigator safety.

The ATSB’s drone project manager, Aaron Holman, says the organisation has been monitoring the emerging technology since 2012.

“The technology has reached a point where we believe it can be usefully deployed to accident sites to assist our investigators and investigations,” Mr Holman said.

Benefits of the drone technology include safety, mapping and recording.

“The biggest benefit is being able to survey an accident site quickly and accurately—the entire accident site,” Mr Holman said.

“We can inspect by drone before sending our investigators in. We can ensure the site is safe.

“We’ll get still images and video which we’ll be able to integrate into our investigation reports, which will make them more interactive and more engaging. We hope to be using the drone before the end of the year.”

Drones, however, do have their limitations.

“They may be less useful in densely forested areas or confined spaces,” Mr Holman said. “They can’t really be used in rain and there are performance limits in windy conditions.”

After watching a demonstration of the drone’s photographic and mapping capabilities north of Canberra recently, ATSB Chief Commissioner Greg Hood is keen to see the technology deployed in the field.

“This will be a useful addition to our investigation armoury and a cost-effective solution across aviation in particular, but also maritime and rail sectors,” Mr Hood said.

As well as lowering the risk to ATSB investigators, there is a significant cost efficiency over mobilising aircraft such as helicopters.

“Although we sometimes piggyback on police aerial resources to assist with our investigations, the cost of assessing an accident site via helicopter can be high,” Mr Holman said. “Using a drone will be cheaper, easier to use and more flexible.

“We’ll be able trace accident flight paths far more accurately and be able to identify strike marks on a tree, for example. This was problematic before this technology became available.”

After testing is completed, the ATSB is likely to deploy drones from its offices in Canberra, Brisbane, Adelaide and Perth.