• Wirestrikes continue to pose serious risks to pilots and passengers.

Three occupants of an R44 helicopter walked away uninjured, after it struck a powerline 142 km west-south-west of Adelaide, South Australia, on 29 March 2015.

The pilot of a Robinson R44 helicopter, was engaged in herbicide dispensing operations near Marion Bay on the Yorke Peninsula in South Australia.

The powerline was not included in information provided to the pilot by local sources, or mapped on the helicopter’s data logger. The pilot had also flown over the area before starting aerial spraying, without sighting the single wire, which ran perpendicular to two other identified, parallel powerlines.   

The helicopter struck the wire, while operating at low level spraying noxious weeds with herbicide. The main rotor blade contacted the wire first, followed by the tail rotor blades. The helicopter sustained substantial damage.

Wirestrikes pose an on-going problem to
aerial agricultural operations.

This accident provides a reminder of the need for consistency in aerial surveys for powerlines, the establishment of standardised procedures for their identification and the need for independent assessment of their presence. 

Single wires can be difficult to see and occur in the most unexpected places in rural areas. ATSB research article Avoidable accidents No. 1 - Low level flying provides additional information on wire hazards associated with flight below 500’.

Avoidable Accidents No. 2 – Wirestrikes involving known wires: A manageable aerial agriculture hazard also explains a number of strategies, developed by the Aerial Agriculture Association of Australia (AAAA) and the ATSB, to help pilots manage the on-going risk of wire strikes.

These strategies include:

• ensure you are physically and mentally fit to fly
• set client expectations so that they are clear that safety comes first
• conduct a thorough briefing and study a detailed map of the area before the flight
• conduct an aerial reconnaissance before spraying and conduct an extra aerial reconnaissance before the clean-up run
• reassess the risks when plans change
• avoid unnecessary distractions and refocus when distracted
• be aware of vigilance limitations
• don’t rely on your ability to react in time to avoid a wire
• actively look for and remind yourself of wires
• be aware of and manage pressures
• have a systematic approach to safely managing wires.

Read the final report: Wirestrike involving a Robinson R44, VH-LOL, 142 km west-south-west of Adelaide, South Australia, on 10 April 2015

• This tragic accident from the Avoidable Accident series highlights the dangers of flying visually in poor weather.

The pilot of a Cessna 337 Skymaster was conducting a private VFR flight from Moorabbin Airport, Victoria to Merimbula, NSW. The pilot, who was only qualified to operate in VMC, had indicated that he would be tracking along the coast at low level. The forecast weather included isolated showers or thunderstorms over the sea and coast, and low cloud over the sea/exposed coast. The low cloud was expected to be broken stratus between 800 ft and 2,000 ft. Visibility was quoted as reducing to 3 km in thunderstorms with rain and 6 km in showers of rain.

About 30 minutes after departing Moorabbin, people on a beach south-east of Venus Bay heard and then suddenly saw the aircraft emerge from fog at low level, flying above the water line on the beach with the wings level. Within seconds it turned right at a steep angle of bank while maintaining height and headed out to sea before disappearing from sight into the fog. The witnesses reported no apparent problem with the engines and the aircraft appeared to be under control. About 2 seconds after the aircraft disappeared from view, they heard a ‘bang’ and then silence.

Two days later, wreckage of the aircraft and three of the deceased occupants were found washed up on the beach. The pilot was not found.

The investigation concluded that while manoeuvring over water at low level in conditions of reduced visibility, the pilot probably became spatially disorientated and inadvertently descended into the water.

By turning away from the land in the foggy conditions, the pilot would have encountered a featureless, grey environment with no visible horizon, making it extremely difficult for him to judge the aircraft’s attitude and/or height.

It should be accepted that flying under the VFR will not always enable you to reach your planned destination. Weather often does not act as the forecast predicts.

It should be accepted that flying under the VFR will not always enable you to reach your planned destination. Weather often does not act as the forecast predicts. You must have alternatives available and you must be prepared to use them — even if it means returning to your departure point.

In forecast marginal weather, careful pre-flight planning is essential and must include a thorough analysis of the latest weather forecasts and consideration of your available options. Those options should be evaluated while en route to ensure you have an alternative course of action available which provides for a safe landing.

Based on ATSB investigation AO-2007-061 - Collision with water, approx. 24 km south-east of Inverloch, Victoria, on 17 November 2007, Cessna C337G, VH-CHU

Know your personal minimums

When deciding on whether it is safe to fly you should consider not only the route to be flown, the prevailing weather and aircraft serviceability, but your own physical and emotional fitness and flying experience. In other words, to be a competent pilot you must know and fly within your own limitations. Adhering to a pre-flight ‘personal minimums’ checklist will go a long way toward keeping you safe. For example, the decision to turn back or divert will be easier if you have decided in advance what your personal minimum VFR flying altitude will be. That minimum altitude may well be much more conservative than the legal requirement.

A ‘personal minimums’ checklist, included in the CASA publication ‘Flight Planning — always thinking ahead’, will help you control and manage risk by identifying risk factors and allowing you to fly with less stress and less risk.

Read more about Accidents involving Visual Flight Rules pilots in Instrument Meteorological Conditions.

• This accident highlights the risks associated with unsealed airfields.

The pilot and two passengers of a Cessna 182 aircraft suffered minor injuries, when the aircraft sank rapidly just before landing. It then landed heavily, bounced into the air, landed again, sank into soft ground, and flipped over.

The property where the airstrip was located had received about 100 mm of rain over a period of two weeks, which had stopped about a week prior to the accident. The surface of the runway appeared to be firm, but a soft layer extended beneath it. The hard landing combined with the soft surface led to the landing gear digging in and flipping the aircraft over. The pilot was unsure what had caused the aircraft to sink.

This incident highlights the importance of the identification and management of risks associated with unsealed airfields. Potential hazards such as changes in the runway surface following rain can be hard to detect. Changes in the runway surface can adversely affect the outcome of a hard landing.

Read the final report: Collision with terrain involving a Cessna 182, VH-AHC, 100 km south-west of Bourke, New South Wales, on 5 July 2015

• Errors can occur irrespective of pilot experience, operator, aircraft type, location and take-off (or landing) performance calculation method.

A data entry error contributed to a slow approach speed and a nose high landing of a Qantas Boeing 737, Adelaide Airport, South Australia in October last year.

Prior to commencing the descent to Adelaide Airport, the monitoring pilot entered an aircraft gross weight of 52 tonnes instead of 62 tonnes into the flight management computer. The computer then calculated flap and landing speeds based on that weight.

During the approach, the monitoring pilot stated that the airspeed was ‘wrong’, but the pilot flying assessed it to be normal and continued the approach. At about 200 ft, the monitoring pilot called ‘speed’ after noticing the speed was trending towards the minimum manoeuvre speed on the airspeed indicator. During touchdown, the aircraft nose was higher than usual; the pitch up was 7.5 degrees, whereas normal is between 3.5 and 3.75 degrees.

Qantas subsequently implemented a requirement for the monitoring pilot to compare landing weight entered to the flight management computer with the load sheet estimated landing weight.

Read the final report: Data input error involving a Boeing 737, VH-XZI, near Adelaide Airport, South Australia, on 12 October 2014

The ATSB’s SafetyWatch initiative identifies data input error as a top aviation safety priority.

More information: Take-off performance calculated and entry errors: A global perspective is a research paper which focused on such incidents and accidents in the 20 years prior to 2009.

Chipmunk aircraft crashes after engine failure

The pilot and passenger of a Chipmunk suffered serious injuries, when their aircraft crashed in a paddock, after the engine failed during a post-maintenance check flight near Luskintyre, New South Wales.

The aircraft had a history of fluctuations in the engine RPM, so the pilot, who was also a maintenance engineer, conducted a check flight including about 10 minutes of normal flight conditions, and some gentle aerobatics. As the engine functioned normally throughout, the pilot then performed a loop. At the bottom of the loop, the engine began to overspeed. The pilot reduced the engine power and turned the aircraft towards to the airfield.

The ATSB urges pilots of single-engine aircraft to plan for partial power loss.

During the approach, the aircraft was unable to maintain altitude. As the pilot turned onto base leg for the runway, the engine failed. The pilot assessed that the aircraft was descending too rapidly to reach the runway, and elected to land in a paddock. Due to strong and gusty wind, with turbulence close to the ground, the aircraft landed heavily. It then travelled through a fence, and sustained substantial damage. A subsequent inspection of the engine did not find a conclusive reason for the overspeed or failure.

Safety message

This accident is a timely reminder to pilots to consider the effect an in-flight engine failure at different altitudes and in the given conditions can have on the options available to manage that failure and to identify a suitable forced landing area. The combination of two people on board and the high temperature would have adversely affected the aircraft’s performance on the day.

The ATSB booklet Avoidable Accidents No. 3 - Managing partial power loss after take-off in single-engine aircraft contains information that is also relevant to a complete engine power loss.

The booklet highlights the importance of:

• pre-flight decision making and planning for emergencies and abnormal situations for the particular aerodrome including a thorough pre-flight self-brief covering the different emergency scenarios.
• taking positive action and maintaining aircraft control either when turning back to the aerodrome or conducting a forced landing until on the ground, while being aware of flare energy and aircraft stall speeds.

Read the final report: Engine failure involving a de Havilland Canada DHC-1, VH-RVY, near Luskintyre, New South Wales, on 14 November 2014

The ATSB urges pilots of single-engine aircraft to plan for partial power loss.

Radio frequency interference at a crowded Melbourne Cricket Ground (MCG) likely resulted in the loss of control and crash of a remotely piloted aircraft. The aircraft was providing media coverage of the cricket World Cup Final on 29 March 2015.

The three-man crew operating the aircraft consisted of a flight controller, a ground station controller, and a camera gimbal controller. The crew launched the aircraft to capture footage as the teams entered the MCG. The aircraft took off from the top of one of the MCG scoreboards and climbed normally to about 300 ft above ground level, tracking south towards Hisense Arena.

About two minutes into the flight, with the aircraft over the northern roof of Hisense Arena, the camera gimbal operator lost control of the gimbal. Seconds later, the ground station controller lost communication with the aircraft. The flight controller decided to discontinue the flight, but found that the aircraft was unresponsive to flight control commands. Aircraft recovery procedures were implemented but ineffective, and continued attempts to regain control were unsuccessful.

The aircraft travelled west for a distance, and after hovering momentarily just south of the Rod Laver Arena, it descended and collided with the ground on the median strip on Batman Avenue. The aircraft and its equipment sustained substantial damage. No one was injured in the collision, and there was no damage to other property.

... this accident highlights the ongoing importance of appropriate RPA operational controls and procedures.

The operator’s report concluded that radio frequency interference was the most likely cause of the accident. The volume of radio frequency traffic at the time of the accident would have been substantial, and perhaps sufficient to affect aircraft control signals. Numerous fixed telecommunications facilities and mobile broadcast vehicles in the vicinity of the MCG were likely to be transmitting at the time of the accident. Over 93,000 people attended the event, many of whom were probably using personal mobile communication devices at about the time of the accident. Furthermore, the use of portable communication devices by event management personnel may also have contributed to the volume of radio frequency traffic.

Read the final report: Loss of operator control involving an Aeronavics SkyJib 8 remotely piloted aircraft, near the Melbourne Cricket Ground, Melbourne, Victoria, on 29 March 2015

All mariners urged to keep a lookout after a collision between container ship and yacht off south-east Queensland.

In the early morning hours of 6 July 2014 in Moreton Bay the container ship Kota Wajar collided with the yacht Blazing Keel. The yacht suffered extensive damage but remained afloat and the yacht safely returned to its marina.

The ATSB found that no one on board either Kota Wajar or Blazing Keel saw the other vessel before the collision. Neither vessel had maintained a proper lookout.

ATSB General Manager of Surface Safety Investigations, Nev Blyth said, ‘This accident was very similar to the 2009 collision between the yacht Ella's Pink Lady and bulk carrier Silver Yang off Point Lookout, Queensland.

‘Back then the ATSB noted there were significant lessons to be learned from this incident and I’m concerned that the message is not getting through’, he said.

Because of the continuing safety issue around maintaining an effective lookout when navigating in Australian waters, the ATSB has issued a safety advisory notice which reinforces the importance of taking all necessary measures to ensure that a proper lookout is kept at all times.

Across the past 26 years, investigations into 41 collisions between trading ships and small vessels on the Australian coast have identified that maintaining a proper lookout is paramount to preventing collisions.

Read the final report: Collision between Kota Wajar and the yacht Blazing Keel, Moreton Bay, Queensland, on 6 July 2014

• The extra risks inherent in visual flight at night are from reduced visual cues, and the increased likelihood of perceptual illusions and consequent risk of spatial disorientation.

The owner and pilot of a Piper Saratoga had held a private pilot licence with a night VFR rating for many years. The pilot was not current in night flying. On 30 March 2011, he had flown from Moree to Brewarrina with five passengers, intending to return that evening.

On the return flight, the pilot made a number of detours to allow the passengers to see particular landmarks, and by the time the aircraft returned to Moree, it was dark.

Two legs of the circuit at Moree Airport were flown toward Moree town centre, which provided enough ground lighting to allow the pilot to control the aircraft. The final approach was over a caravan park and highway. However, there was relatively limited ground lighting along the aircraft’s intended flight path in the last 500 m before the runway, except for the runway lighting ahead.

The aircraft was very low on the final leg of the circuit. The left wing impacted the top of a tree in the caravan park, 700 m north of the runway. The aircraft rolled inverted and impacted the ground about 150 m later. Two passengers survived the
accident.

Lessons learnt

Even if there is ground lighting, terrain clearance will be assured by continually matching the aircraft’s position in the circuit and on the approach against the expected altitude. This check allows a pilot to correct the height early if needed. Night currency enables a pilot to maintain the necessary skills and judgement to safely fly at night, such as an earlier detection and correction of an undershoot or shallow approach path

Key message

The extra risks inherent in visual flight at night are from reduced visual cues, and the increased likelihood of perceptual illusions and consequent risk of spatial disorientation. These dangers can, however, be managed effectively. This report explains how suitable strategies can significantly reduce the risks of flying visually at night.

• Night flying is more difficult than flying in the day. Ensure you are both current and proficient with disciplined instrument flight. Know your own personal limitations in terms of flying with minimal or no visual references. Only fly in environments that do not exceed your capabilities.
• Before committing to departing on a visual flight at night or close to last light, ensure your aircraft is appropriately equipped and consider all obtainable operational information, including the availability of celestial and terrestrial lighting.
• Some nights and some terrain are darker than others. Excellent visibility conditions can still result in no visible horizon or contrast between sky and ground. Inadvertently flying into instrument meteorological conditions (IMC) is also harder to avoid at night.
• Always know where the aircraft is in relation to terrain, and know how high you need to fly to avoid unseen terrain and obstacles.
• Remain aware of illusions that can lead to spatial disorientation—they can affect anyone. Know how to avoid and recover from illusions by relying on instrument flight.

Read more about: Visual flight at night accidents

Read the final report: Controlled flight into terrain involving Piper Saratoga PA-32R-301T, VH-LKI, Moree Airport, New South Wales, on 30 March 2011

Learn more about Flying with reduced visual cues

• Pilots must operate within personal limits when flying in darker environments. Night ratings and instrument ratings entitle pilots to fly at night, but the skills needed to fly over a city at night are very different from the skills necessary to fly when there is nothing to be seen.

Ten minutes after the end of daylight on 27 July 2011, the pilot of a Robinson R22 helicopter took off from Big Rock Dam stockyards on Brooking Springs station to fly back to the homestead, a flight that would normally take 30–40 minutes.

The route normally used flew over an area devoid of ground lighting, then over a limestone ridge to a plain, from which the lights of Fitzroy Crossing would come into view. At some point from there, the flight would be diverted to the Brooking Springs homestead.

The pilot took off at about sunset, and initially flew at normal cruising speed, but gradually slowed until the helicopter orbited over a dirt track before heading towards Fitzroy Crossing. Thirty minutes after the end of daylight, the helicopter flew very low and very slow, possibly flying by reference to terrain visible through illumination from the helicopter’s landing lights. Ten minutes later, when it would have been fully dark, the helicopter climbed from about 100 ft to 600 ft above ground level, and turned towards the homestead. During the turn, the helicopter increased groundspeed from 5 to 95 knots, attained a rate of descent, and collided with the terrain. The pilot sustained fatal injuries during the accident.

The pilot had never received night flying training or obtained a Night Visual Flight Rules rating. The aircraft was equipped with suitable lighting for night flight, but it did not have the necessary instrumentation or other equipment necessary to enable a pilot to fly safely by night.

In this accident it is likely that the pilot lost control of the helicopter due to spatial disorientation from insufficient visual reference to keep the helicopter the right way up.

Lessons learnt

Many things must be in place for a safe night flight to happen. Do not fly at night unless you are trained and qualified to do so and you know all the requirements and are able to apply them.

A flight that cannot be completed by nightfall should not even be started unless all the necessary requirements are in place to allow a safe night flight and landing.

In very dark conditions such as rural areas, the skills needed to fly an aircraft at night are vastly different to day VFR flight, and may even exceed the capabilities of some pilots trained in night VFR operations.

Key message

The extra risks inherent in visual flight at night are from reduced visual cues, and the increased likelihood of perceptual illusions and consequent risk of spatial disorientation. These dangers can, however, be managed effectively. This report explains how suitable strategies can significantly reduce the risks of flying visually at night.

• Night flying is more difficult than flying in the day. Ensure you are both current and proficient with disciplined instrument flight. Know your own personal limitations in terms of flying with minimal or no visual references. Only fly in environments that do not exceed your capabilities.
• Before committing to departing on a visual flight at night or close to last light, ensure your aircraft is appropriately equipped and consider all obtainable operational information, including the availability of celestial and terrestrial lighting.
• Some nights and some terrain are darker than others. Excellent visibility conditions can still result in no visible horizon or contrast between sky and ground. Inadvertently flying into instrument meteorological conditions (IMC) is also harder to avoid at night.
• Always know where the aircraft is in relation to terrain, and know how high you need to fly to avoid unseen terrain and obstacles.
• Remain aware of illusions that can lead to spatial disorientation—they can affect anyone. Know how to avoid and recover from illusions by relying on instrument flight.

Read more about: Visual flight at night accidents

Read the final report: Collision with terrain involving Robinson R22 helicopter, VH-YOL, 14 km north-west of Fitzroy Crossing, Western Australia, on 27 July 2011

Learn more about: Flying with reduced visual cues

On 23 February 2015, two crew were seriously injured by a falling load spreader on Happy Buccaneer in Port Hedland, Western Australia.

A technician and the bosun had worked together to remove a sling hook from lowest of a pack of four load spreaders. Each load spreader was 4 m long by 1.2 m wide and weighed 2.4 t. The pack of four had not been secured into a single unit prior to being lifted.

After removing the hook, and as the two men walked alongside the stacked load spreaders, the bosun signalled to the crane operator to raise the crane’s hook. As the hook was raised a hammerlock (joining link) on the chain sling most likely caught the lip of the topmost load spreader, tipping it off the pack and onto the two men.

The technician’s right leg was pinned 
under the load spreader and he had fractured both legs.

The technician’s right leg was pinned under the load spreader and he had fractured both legs. The bosun was not trapped but suffered fractures to his lower left leg. Both men required extensive surgery and the technician also had his right leg amputated below the knee.

The ATSB identifies some simple safety precautions that must apply to crane operations.

• Lifting and handling procedures and practices should use a risk assessment to anticipate the hazards and to minimise the associated risks.
• Crane operators, banksmen (dogmen) and assisting crew should be aware of each other’s location and the movement of suspended loads.
• Rigging gear needs to be guided until it is free of obstacles and equipment.
• Multiple loose items need to be combined and secured to form a single unit prior to lifting.
• Clear communications by hand, radio or other methods must be practiced and emphasised during lifting operations.

Read the final report: Serious injury to crew on board Happy Buccaneer, Port Hedland, Western Australia, on 23 February 2015