Runway incursions are an ongoing safety concern at airports. This incident shows just how easily they can happen, even while following procedures and carrying out routine duties.

The incident occurred shortly after an ATR 72 aircraft, operated by Virgin Australia Regional Airlines, broadcast on the common traffic advisory frequency (CTAF), that they ‘should be turning straight in for a landing runway 16’.

At about the same time, the aerodrome reporting officer (ARO) was asked by airport ground staff to conduct a runway inspection, following a birdstrike report of another aircraft that just landed. He entered a safety vehicle, which was fitted with a flashing orange beacon, and then drove to the holding point for runway 16/34.

The ARO broadcast on the CTAF advising that the vehicle was preparing to enter the runway for a runway inspection. The ARO heard a beep-back, confirming that he had made the call on the correct frequency, but no other response was heard on the CTAF.

...the ARO heard ‘car vacate’ broadcast on the CTAF and sighted the aircraft landing on the far end of the runway in the rear-view mirror of the vehicle.

The CTAF broadcasts an automatic voice-back response if no calls have been made on the frequency for five minutes; otherwise a beep-back is broadcast. The ARO assumed that he received a beep-back rather than a voice-back, due to the calls made by the crew of the aircraft that had just landed.

He then conducted a thorough lookout for aircraft approaching and did not sight any. The ARO broadcast that he was entering the runway and commenced driving north along the runway. When at the northern threshold, the vehicle turned and drove south along the runway with no evidence of a birdstrike found.

The crew of the ATR 72 did not hear either broadcast from the ARO. The aircraft was in cloud during the approach, with the cloud base at about 2,600 feet and encountered some turbulence on final, with a crosswind of about 12 kt. The captain looked up out of the cockpit along the runway and sighted the safety vehicle on the white runway aiming point markings near the far end of the runway and immediately broadcast ‘car vacate’. (The first officer sighted the orange beacon when at about 10 feet AGL, but was not immediately aware that it indicated the presence of a vehicle on the runway).

When about 100 m from the southern end of the runway, facing south, the ARO heard ‘car vacate’ broadcast on the CTAF and sighted the aircraft landing on the far end of the runway in the rear-view mirror of the vehicle.

The ARO immediately drove the vehicle off the runway and once clear, broadcast that the safety vehicle had now vacated all runways.

The ARO had a handheld VHF radio and a VHF radio was fitted in the safety vehicle. When in the vehicle, the ARO switched off the handheld radio to avoid interference with the fitted radio. The ARO could alternatively be contacted via mobile phone. The ARO also had a UHF radio which was used to communicate with aerodrome ground staff. All normal communications between flight crew and the ARO are on the CTAF via VHF radio. The ARO reported that inside the terminal building there was a ‘black spot’ for VHF reception.

The ATSB was provided with the CTAF recordings. Both of the broadcasts made by the ARO included the standard phraseology of prefixing and suffixing each call with ‘Traffic Moranbah’ to alert aircraft to the location of the caller.

The ATSB’s investigation found that the ARO was in the airport compound for the duration of the calls broadcast at 25 NM, 10 NM and overhead by the aircraft. This meant he was not aware the aircraft was in the vicinity. The recording of the CTAF obtained by the ATSB verified all calls made by the crew of the aircraft and the ARO. The ARO calls were audible but less clear than the aircraft calls; however it could not be determined why the crew of the aircraft did not hear the ARO broadcasts. There was no requirement for the ARO to maintain a continuous listening watch on the CTAF. Six minutes elapsed between the broadcast from the captain of the aircraft overhead the aerodrome, to the call to the car to vacate.

Read the final report: Runway incursion involving an ATR 72, VH-FVI, and a vehicle, Moranbah Airport, Queensland, on 5 March 2014

Safety message

Safety around non-controlled aerodromes is one of the ATSB’s major safety priorities. Research conducted by the ATSB found that, between 2003 and 2008, 32 runway incursions were recorded at non-controlled aerodromes. Broadcasting on and monitoring of the CTAF is the key way for pilots to establish situational and traffic awareness. The ATSB Limitations of the see-and-avoid principle study found that the effectiveness of a search for other traffic is eight times greater when a radio is used effectively in combination with a visual lookout, than when no radio is used. A pilot's guide to staying safe in the vicinity of non-controlled aerodromes is also a good source of information.

• Carburettor icing can happen at temperatures of up to 38 degrees Celsius.
• Carburettor heat should be applied immediately when an engine runs roughly.

Carburettor icing can occur even in relatively warm conditions - the higher the humidity, the more likely it is that ice will form in the air-intake system.

Carburettor icing likely contributed to an accident on 14 July 2015, when the pilot of a Robinson R44 helicopter was conducting aerial mustering operations on a property near Alice Springs.

The pilot felt a small vibration, and initially thought it was due to loose tape on the main rotor blade. The pilot looked for a suitable landing site, but the vibration increased significantly.

Carburettor icing can happen at temperatures of up to 38 degrees Celsius – it is less likely at very cold temperatures.

As the helicopter descended, the pilot maneuvered it through a gap between trees, and pushed the cyclic forward to maintain airspeed. The pilot lowered the collective and noticed the engine seemed to go very quiet. The low rotor revolutions per minute warning horn sounded. The pilot made a radio call to advise another pilot operating nearby that the helicopter was going down. The pilot then flared the helicopter to try to cushion the landing impact. The right skid touched down first, and the helicopter rolled onto its right side.

The pilot sustained minor injuries, and the helicopter was substantially damaged. The weather was fine with no visible signs of moisture and the pilot did not turn the carburettor heat on at any stage during the flight.

According to the Carburettor Icing Probability chart, current conditions indicated a high probability of serious carburettor icing at descent power. At the time it was 12 degrees Celsius with relatively high humidity of 40 – 45 per cent.

The icy facts:

• Carburettors cause evaporation, which cools the air.
• Carburettor icing can happen at temperatures of up to 38 degrees Celsius – it is less likely at very cold temperatures.
• Carburettor icing is more likely at partial power settings because of the cooling effect of a partly closed throttle butterfly.

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Safety message

Carburettor heat should be applied immediately when an engine runs roughly.

Apply carburettor heat immediately as per the emergency checklist in the approved operating handbook or aircraft flight manual for your aircraft type.

Use this CASA probability chart(Opens in a new tab/window) to work out the risk of carburettor icing prior to each flight.

Read the final report: Collision with terrain involving a Robinson R44, VH-VOH, 130 km east of Alice Springs, Northern Territory, on 14 July 2015

More information:

• The ongoing danger of carburettor icing
• Carburettor icing suspected in loss of engine power
• Know the risk of carburettor icing before flying

• Don’t let lack of sleep affect your fitness to fly.

Pilot fatigue contributed to an incident where an Avro 146 jet received two separate warnings for flying below the minimum altitude, according to an ATSB report.

The incident occurred on 23 June 2015 when the captain and first officer of the Jet Express aircraft were flying from Perth to Granny Smith Airport, north of Kalgoorlie Western Australia. The aircraft had five crew and 67 passengers on board.

While approaching Granny Smith Airport, the captain observed the radio altimeter (RADALT) indicating 500 ft and the electronic ground proximity warning system (EGPWS) called ‘500’, both indicating the aircraft was 500 ft above the ground. Shortly afterwards, the crew received an EGPWS ‘DON’T SINK’ warning. The first officer then observed the RADALT indicating 380 ft and the vertical speed indicator showing about 100 ft per minute descent. The captain immediately applied nose-up pitch and increased the thrust. The aircraft climbed and the captain levelled the aircraft off to remain clear of cloud. The crew then received a second ‘DON’T SINK’ warning. The first officer noted the RADALT indicating 410 ft and the captain immediately initiated a go-around, climbing to 4,000 ft AMSL.

Due to the time spent operating with the aircraft in the approach configuration, and the possibility of holding required in Perth, the captain elected to divert and land at Kalgoorlie.

In the 24 hours before signing on for duty, the captain had about three hours’ sleep and felt irritable, with poor concentration, heavy eyes, and slow thinking processes. The captain believed decision-making had been affected by lack of sleep.

This incident serves as a warning to pilots on how fatigue can affect performance. In fact, less than six hours sleep in the previous 24 hours is associated with degraded operational performance and increased error rates.

Safety message

Prior to flight, it is important for pilots to assess their fitness to fly. The following checklist provides a quick reference.

• Don’t let lack of sleep affect your fitness to fly.
• Less than 6 hours sleep in the previous 24 hours is associated with degraded operational performance and increased error rates.
• Fatigue research has demonstrated that humans are quite poor at determining how fatigued they actually are.

A description of aeromedical factors is available in the US Federal Aviation Authority Pilot’s Handbook of Aeronautical Knowledge(Opens in a new tab/window).

Read the final report: Flight below minimum altitude involving an Avro 146, VH-NJW, near Granny Smith Airport, Western Australia, on 23 June 2015

• 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 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

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