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.

A hard landing of a Maule MT-7-235 aircraft at Greenfields airstrip near Noosa in Queensland on 16 May 2016 highlights why it’s important for pilots to conduct a go-around when in doubt.

The requirement for three take-offs and three landings in the last 90 days is a regulatory requirement for pilot currency, but this does not guarantee pilot proficiency. Pilots need to be ‘go-around prepared’ because the execution of a go-around is an infrequent manoeuvre.

The pilot had flown about five flights, totalling about 20 hours in the previous 12 months and the pilot’s last flight was about four-to-five weeks prior to the accident flight.

When flying infrequently, proficiency in take-offs and landings can be improved by dedicating a portion of the flight to practicing circuits, including go-arounds. The United States Federal Aviation Administration describes this as ‘imbuing the quantity of flying, however limited, with quality.’

The Maule pilot conducted a private flight from Greenfields with two passengers on board. After a trip that included a re-fuel at Gympie, the flight headed north towards Maryborough before returning to Greenfields along a coastal route.

On final approach to Greenfields, the pilot noticed they were getting low. At about 500 ft, they increased the power to regain their approach path. The pilot subsequently assessed that the aircraft was too high and lowered the nose to re-intercept the approach path.

The pilot flared the aircraft for landing, the aircraft landed heavily and bounced into the air. As the aircraft landed again, the nose wheel touched down first (before the main landing gear) with sufficient force that the nose wheel strut fractured.

The nose landing gear and propeller then dug into the ground and the aircraft rotated over its nose and slid a short distance inverted before coming to rest. The pilot and one passenger were uninjured, another passenger sustained minor injuries, and the aircraft sustained substantial damage.

The pilot had not operated the Maule aircraft with more than one passenger on board prior to the accident flight and felt that the higher all-up-weight of the aircraft with an extra passenger on board may have contributed to a higher sink rate on final approach.

The pilot later formed a view that a go-around, rather than continuing with the landing manoeuvre, would have been a better option.

Take-off and landing phases of flight are critical, since the aircraft is operating closer to the stall speed and with less height to recover from a control problem, relative to cruise flight.

A go-around could have prevented an unstable approach and initial bounce from escalating to an accident.

Read the final report: Hard landing involving Maule MT-7, VH-DRS, near Noosa, Queensland, on 16 May 2016

Enhanced safety actions will help reduce risks for aircraft and ambulance operators at Blackall Airport in Queensland.

This follows a runway incursion involving an aeromedical Hawker Beechcraft B200 aircraft and an ambulance on the night of 28 February 2016.

At about 2.30 am the plane was descending to Blackall Airport with a pilot, a doctor and a nurse on board.

Earlier, at about 2.20 am, an ambulance driver was dispatched to Blackall Airport by the ambulance coordination centre to meet the aircraft for patient transportation. The ambulance driver was the only occupant of the vehicle.

A series of events involving missed communication and sighting between the ambulance and the aircraft resulted in the Beechcraft B200 initiating a missed approach.

The pilot climbed and entered a hold pattern about 5,000ft above the airport before descending and landing without incident.

As a result of this occurrence, the aircraft and ambulance operators have advised the Australian Transport Safety Bureau (ATSB) of a range of safety actions to be implemented.

For the aircraft operator, runway strip inspections will continue for night operations at all aerodromes with known or suspected animal hazards and where appropriate ground personnel can safely conduct inspections.

Formal procedures will be developed in conjunction with the ambulance operator detailing safety procedures for those rural/regional stations where a request for a runway inspection is likely.

Appropriate procedures will be developed for requesting airstrip inspections for incorporation in the airstrip data manual.

And there will be closer safety liaison between the respective ambulance and operator safety departments.

The ambulance operator has advised the ATSB that staff working at Blackall Airport will attend the airport operator induction program.

Consultative arrangements with occur with key stakeholders and there will be a review of local UHF/VHF radio communications procedures between the operation centre, aircraft operator, airport operator, and ambulance attending the airport.

In addition, there will be a review of induction programs for staff in consultation with the aircraft operator and the airport. All new and existing staff will participate in a revised induction program. Induction workbooks will be reviewed and all new and existing staff will be provided with a copy of the workbook.

A review of the Blackall standard operating procedures will be conducted to ensure that procedures cover all aviation safety requirements.

The International Civil Aviation Organization (ICAO) has identified runway safety as one of its priorities and has been working with countries and aviation organisations globally to reduce runway safety accidents. ICAO has a runway safety website and has published a Manual on the prevention of runway incursions (Doc 9870 AN/463), available on the website.

Additional information on runway safety is available from Airservices Australia, including The airside drivers guide to runway safety.

Read the final report: Runway incursion involving Hawker Beechcraft Corporation B200, VH-FDG, and vehicle, Blackall Airport, Queensland, on 28 February 2016

An effective response to an emergency situation ensured the safe arrival of Qantas Airbus A380 flight QF7 from Sydney to Dallas, Texas, on 15 May this year.

About two hours prior to arrival at Dallas-Fort Worth, United States, a passenger alerted cabin crew to smoke in the cabin. Cabin crew initiated the basic fire drill procedure and the customer service manager (CSM) made an emergency call on the aircraft interphone to alert all crew to the presence of smoke.

Cabin crew located the source of the smoke and removed seat cushions and covers while the CSM turned off power to the centre column of the seats.

On further investigation, the crew found a crushed personal electronic device (PED) wedged tightly in the seat mechanism. The PED contained a lithium battery.

A rapid and coordinated response by the crew ensured the situation was effectively managed and the safe landing of the aircraft.

The incident highlights the hazards of transporting lithium-ion battery powered PEDs on aircraft. More than a billion lithium batteries are believed to be transported by air every year, with potentially hundreds carried on single sectors on large aircraft.

The ATSB has received 17 notifications of similar incidents of lithium battery thermal events in aircraft over the past six years.

Cabin crew and passenger education remains a key component to managing these events. The Civil Aviation Safety Authority web page Travelling safely with batteries and pamphlet Is your luggage safe? provides information on the safe carriage of lithium-ion batteries and lithium-ion powered devices aboard aircraft.

Read the final report: Smoke event involving Airbus A380, VH-OQD, about 1,500 km west-south-west of Dallas-Fort Worth Airport, United States, on 16 May 2016