Source: South Australia Police

An ATSB investigation into a landing accident involving a Van’s RV-6A at William Creek, South Australia on 28 July 2019 found that the aircraft’s nosewheel landing gear’s strut or fork made contact with the runway, bending the nose gear under the aircraft.

The accident occurred when the aircraft was landing on an unsealed runway at William Creek. During the landing, the aircraft’s main gear touched down first, before the nose gear touched down momentarily. The pilot would later note that although the nose gear lifted off the runway, the main gear stayed on the runway.

When the nose gear made contact with the runway surface for the second time, it bent under the aircraft. The propeller then struck the runway and the aircraft skidded on its nose before flipping over coming to a rest inverted. The pilot sustained serious injuries and the passenger minor injuries, while the aircraft was substantially damaged.

Pilots of tricycle variants of Van’s aircraft need to take into account the many factors that can affect the ground clearance of their aircraft’s nose gear.

The ATSB investigation found that during the landing sequence the nose gear fork or strut made contact with the runway surface and bent underneath the aircraft. The investigation also established that the nose gear’s strut and fork had sustained no fractures, and that instead, the top of the strut had bent, near the engine mount.

“A reduction in the nose gear ground clearance during landing can result in the nose gear strut or fork impacting the runway and affect the structural integrity of the nose gear,” said ATSB Director Transport Safety Stuart Macleod.

“In the tricycle variants of Van’s aircraft, the factors that can affect nose gear ground clearance include the dynamics of the landing, tyre pressure, weight over the nose gear, and runway condition and characteristics.”

In 2007, Van’s issued a mandatory Service Bulletin with a redesigned nose gear that provided greater clearance. The aircraft that flipped at William Creek was compliant with this Service Bulletin and was also fitted with two after-market devices aimed at reducing the risk of a nose-gear collapse and aircraft inversion.

Read the final report: Landing accident involving Van’s RV-6A, VH-ANU, William Creek ALA, South Australia, on 28 July 2019

Corrosion in the carburettor of a Cessna 182’s engine, which led to a power loss after take-off and a subsequent forced landing, demonstrates the importance of following maintenance periodic inspection requirements. 

On the morning of 6 January 2019, Cessna 182 registration VH-DGF took off from Tooradin Airfield, Victoria for skydiving operations with the pilot and four parachutists onboard. The aircraft continued to climb but at about 400 ft the engine sustained a sudden power loss. Climb performance was affected and the propeller windmilled.  

The pilot lowered the aircraft nose and identified a suitable location for a forced landing. The aircraft touched down in a relatively flat and open paddock and initially bounced and passed through two boundary fences. The left wing strut then collided with a tree, folding the left wing over on top of the right wing. The Cessna then collided with a third fence, crossed a private road and collided with a fourth fence collapsing the nose landing gear where it come to a stop.

With limited time and height available, the pilot displayed sound airmanship and decision making.

The aircraft was substantially damaged, but there were no injuries to the pilot and passengers. However, the investigation report does note that by not wearing the available upper torso restraint the pilot exposed himself to significant unnecessary injury risk, and highlights that a substantial body of research shows that wearing an upper torso restraint significantly reduces the risk of injury compared to just wearing a lap belt only. 

Following the accident, subsequent examination of the carburettor found a significant amount of aluminium oxide deposits in the carburettor float bowl and directly below the carburettor nozzle and main jet assembly.  

Loose aluminium oxide deposits likely blocked fuel flow within the carburettor resulting in the engine losing power shortly after take-off. 

With limited time and height available, the pilot displayed sound airmanship and decision-making by accepting the risk of a minor accident and conducting a forced landing rather than turning back and risking loss of control and the possibility of a much more serious outcome, the report notes. 

This investigation also highlights the importance of following the maintenance program for your aircraft to ensure its serviceability, particularly as in this case, draining and flushing the carburettor at its periodic inspection. 

The ATSB was unable to determine the extent to which this action was actually conducted during the six inspections since the engine and carburettor were overhauled in December 2011.   

Read the final report: Loss of power on take-off and forced landing involving Cessna 182, VH-DGF, Tooradin, Victoria, on 6 January 2019

Source: Cobham

Ineffective execution of checklists and the absence of nose-wheel chocking contributed to an Avro RJ85 airliner rolling forward after engine start and colliding with aircraft stairs and a light pole at Perth Airport, a new ATSB report details.

During the 30 July 2019 occurrence, the flight crew of a Cobham Aviation Avro RJ85 were preparing their aircraft for departure for a charter flight with two cabin crew and 62 passengers on-board.

The subsequent ATSB investigation found that the flight crew did not effectively check the brake system pressure during two separate pre-flight checklists, which meant they did not detect that there was insufficient pressure within the braking system, and did not identify that the system needed to be pressurised prior to engine start. (The aircraft had been parked after its previous flight for a number of hours; longer than the brake accumulator reservoir could retain pressure.)

The ATSB found that the initial and primary missed checks related to the captain not performing checklist items as required, and the first officer not effectively monitoring the checking actions of the captain and not independently checking the pressure systems.

Because of the missed checklist items, on engine start there was no brake pressure in the aircraft’s parking brake system. Once the captain gave the ground engineer clearance to remove the main wheel landing gear chocks, there was no other restraint in place to prevent an inadvertent roll forward, as the operator’s procedures did not involve repositioning chocks on the nose-wheel of departing aircraft.

Once started, the combined thrust of the aircraft’s four engines at idle power and the slight apron slope caused the aircraft to inadvertently roll forward.  The crew attempted to apply the aircraft brakes. However, because there was no brake pressure, these attempts were ineffective.

The normal after-start checks would have pressurised the brakes, however because the crew were responding to the unexpected roll-forward, they did not perform these checks. The ATSB found that the crew had a very limited opportunity to take corrective action to prevent the collision. The close proximity of the edge of the apron and the surprise associated with the unexpected roll-forward reduced the crew’s ability to respond before it collided with portable aircraft stairs. The aircraft then collided with a bollard in front of a light pole, and then the light pole itself.

“This investigation highlights the importance of ensuring all checklist items are addressed,” says ATSB Executive Director Transport Safety Nat Nagy.

“As highlighted in this accident, individuals can be vulnerable to omitting checklist items and this can lead to accidents.

“Aviation safety relies on a resilient safety system involving multiple defences. In the context of multi-crew operations, one of the key defences against this type of accident is the other pilot monitoring and cross-checking the pilot who is completing the checklist. This can provide a last line of defence to trap individual errors.”

Mr Nagy also noted that although safety systems should seek to reduce errors developing, where possible engineering defences, like wheel chocks, should also be used to reduce error consequences.

The report notes that Cobham have reiterated to their check and training captains the importance of vigilance during checklists, and that they were planning to update procedures to require the use of nose-wheel chocks when dispatching aircraft from stand-off bays.

Read the final report: Ground collision with airport infrastructure involving British Aerospace AVRO 146-RJ85, VH-NJW, Perth Airport, Western Australia, on 30 July 2019

After a loss of engine power, probably due to insufficient fuel or an in-flight fuel management error, a twin-engined Cessna 310 aircraft did not maintain a safe flying speed before it collided with terrain just short of the runway, an ATSB investigation has found.

The Cessna T310R was on approach to land at a private airfield at The Lakes, adjacent to the Pacific Highway south of Port Macquarie on the NSW North Coast, while conducting a private flight from Toowoomba, Queensland, with a pilot and passenger on board. When the aircraft was about 8 km from the runway, a witness recalled hearing what he thought was a single-engine aircraft ‘cough’ and then stop. A separate witness, who was driving south on the Pacific Highway, recalled seeing the aircraft descending slowly, then roll to the left, pitch down and descend rapidly to the ground.

The aircraft was subsequently found to have collided with terrain, coming to rest in a narrow-wooded strip of land between the highway and the main northern railway line, about 800 metres from the runway threshold. The pilot and the passenger were fatally injured, and the aircraft was destroyed in the accident.

The ATSB investigation identified that during the final descent, the aircraft’s left engine was not producing power and the right engine was operating at low or intermittent power. The loss of engine power was probably the result of either insufficient fuel for the flight or an in-flight fuel management error.

It is imperative that the pilot retains control of the aircraft and maintains a safe airspeed.

Despite that power loss, examination of the wreckage identified that the aircraft was configured for a powered approach, in a high‑drag configuration with the left and right engine propellers unfeathered, the landing gear down and the flaps partially extended. The low engine power combined with the high-drag configuration meant that the aircraft’s speed and altitude could not be maintained.

The investigation report notes that maintenance of a high‑drag configuration while the aircraft’s performance declined indicated that either the pilot did not recognise any engine abnormalities until late in the approach or assessed that sufficient engine power remained to reach the runway.

ATSB Chief Commissioner Greg Hood said this accident highlighted how a loss in power requires different responses depending on whether an aircraft has single or multiple engines.

“However, regardless of the configuration, in order to maximise the survivability outcome, it is imperative that the pilot retains control of the aircraft and maintains a safe airspeed,” Mr Hood said.

“Where the aircraft’s performance degrades to the point that continued safe flight is not possible, the pilot must shift their focus to conducting a forced landing.”

Mr Hood also stressed that pilots need to routinely follow recognised fuel management practices in order to maintain the highest level of safety and avoid fuel exhaustion or starvation events.

The Civil Aviation Advisory Publication 234-1(2)(Opens in a new tab/window) provides important guidance on the current fuel requirements and good fuel-management practices.

Read the final report: Loss of control and collision with terrain involving Cessna T310R, VH-JMW, 40 km south-south-west of Port Macquarie, New South Wales, on 28 October 2017

The driver of an empty passenger train that passed two signals at ‘Danger’ and entered a level crossing before the crossing booms had lowered was probably influenced by nicotine withdrawal symptoms, an ATSB investigation has found.

The 2 January 2018 incident occurred when a V/Line three-car VLocity train (number 7750) was repositioning on a non-passenger-carrying service from the outer Geelong, Victoria suburb of Waurn Ponds to Geelong Station, from where it was due to operate a passenger service to Melbourne’s Southern Cross Station. Shortly after passing Marshall Station, the train passed two signals at Danger (MSL10 and MSL8), entered the single line section between Marshall and South Geelong, and then entered the Marshalltown Road level crossing before the crossing booms had lowered.

At about the same time a V/Line Melbourne to Warrnambool service, with two crew and 166 passengers on-board, had departed Geelong and was heading towards Marshall on the same single line section. The trains were scheduled to cross using the loop track at Marshall. When the train controller in Melbourne became aware that train 7750 was passing signals at Danger, the controller initiated an emergency radio fleet call instructing both trains to stop. When stopped, the distance between the trains was about 940 metres.

The subsequent investigation into the occurrence, conducted on behalf of the Australian Transport Safety Bureau (ATSB) by the Victorian Government Office of the Chief Investigator, Transport Safety, determined that the driver’s performance was probably influenced by symptoms associated with nicotine withdrawal, having not applied a nicotine patch on that day.

Attempts by safety-critical workers to stop smoking should be managed under medical supervision.

The investigation report notes that nicotine withdrawal symptoms typically become apparent within a few hours of last nicotine exposure, and that task-related effects can include difficulty concentrating, memory impairment and attention difficulties. These and other symptoms of nicotine withdrawal probably had an adverse effect on the performance of the driver.

Further, the driver of train 7750 also tested positive for an inactive metabolite of cannabis, with levels suggesting use within the previous seven days. However, it could not be determined whether cannabis use had affected the driver’s performance at the time of this incident.

“Nicotine withdrawal can affect a driver’s performance. To minimise adverse impacts, attempts by safety-critical workers to stop smoking should be managed under medical supervision,” said Chris McKeown, Chief Investigator, Transport Safety.

The report also notes that at the time of the incident, signalling at Marshall did not include any additional enforcement controls to protect against a train exceeding its authority.

Subsequent to the incident, V/Line installed a train protection system at Marshall to stop a train that has passed a signal at Danger. The system also has several over-speed sensors to prevent a train entering the Marshalltown Road level crossing when unprotected.

As part of other infrastructure projects, V/Line also continues with planning for the provision of three-position signalling for this section of track.

“This investigation highlights that rail operators should consider fitting authority-overrun intervention at locations, such as at Marshall, that present a heightened risk due to rail operations on a single, bidirectional track,” Mr McKeown said.

Read the final report: Signals passed at danger by train 7750, at Marshall, Victoria, on 2 January 2018

Why the driver of a suburban passenger train did not slow the train before it collided with the buffer stop at Richmond Station in Sydney’s northwest on 22 January 2018, resulting in injuries to 16 people, could not be conclusively determined, an investigation into the event notes.

The eight-car Waratah class passenger train (designated A42) collided with the buffer stop at the end of Richmond Station’s platform 2 at a speed of about 26 km/h.

A number of possibilities for the driver’s inaction were examined during the course of the investigation, which was conducted on behalf of the Australian Transport Safety Bureau (ATSB) by NSW’s Office Transport Safety Investigations (OTSI). These included: the driver blacking out; the driver experiencing a microsleep due to fatigue impairment; or the driver being distracted or inattentive.

The buffer stop withstood the impact of the collision and prevented the train from crossing onto a main road, the investigation found. But the investigation also concluded that the two hydro-pneumatic rams on the front of the buffer stop did not perform as designed, due to their non-alignment with the crash energy management system on the front of the Waratah train.

In addition, the crash energy management system on A42 did reduce the impact force of the collision, but not all components performed as designed.

Rail operators should ensure that multi-layered defences are in place against over-speeding.

“Rail operators should ensure that multi-layered defences are in place against over-speeding,” said Mick Quinn, OTSI CEO and chief investigator.

“This should include infrastructure design, rolling stock design and train crew health management. They need to ensure that identified risk controls are implemented, and that these control measures are effective in their performance.”

Mr Quinn said that if the driver’s cab had been fitted with an inward-facing camera, the footage may have provided investigators with an insight to why the driver was unresponsive leading up to the collision.

“Having audio and video recordings would allow investigators to eliminate, early in the investigation, potential contributory factors,” he said.

Since the accident, Sydney Trains has proactively addressed a number of safety issues, including redesigning the buffer stops for Platforms 1 and 2 at Richmond, while intermediate train stops, previously identified and recommended as a risk control, have been installed at Richmond.

However, the ATSB has issued a formal safety recommendation calling for Sydney Trains to take action to ensure that existing procedures regarding train crew rest breaks between shift cycles are adequate and start time rotations are reinforced to safeguard against fatigue impairment of train crews.

Finally, the report notes that automatic train protection, which if installed on A42 may have prevented the incident, was still being trialled at the time of the incident. Transport for New South Wales has scheduled automatic train protection to be operational on most Sydney Trains electric rolling stock by May 2021.

Read the report: Collision of Waratah passenger train A42 with buffer stop, at Richmond Station, New South Wales, on 22 January 2018

A Fokker F100 airliner inadvertently returned to service with a lock-out bolt installed, rendering one of its two engine thrust reversers inoperative.

An incorrect type of lock-out bolt used during maintenance the previous day meant that when the captain selected reverse thrust on landing at Karratha on a 27 December 2017 flight from Perth, the right engine thrust reverser did not activate. The aircraft was able to decelerate using normal braking and taxied to the gate without further incident.

An ATSB investigation found that during a maintenance task to inspect the aircraft engines’ emergency fuel shut-off cables, to safely isolate the thrust reverser mechanism a maintenance engineer installed the incorrect lock-out bolt, and then did not remove it after the maintenance was completed.

The investigation found that the engineer used the more conveniently located in-service lockout bolt from the aircraft’s flight deck for the task, instead of the appropriate maintenance lockout bolt, which is fitted with a large red warning flag, and had to be checked out of the tool store. As a consequence, the lock-out bolt did not show as missing during a tooling inventory check as the aircraft was released to service.

Further, there were no warning labels in the cockpit to warn the flight crew that the bolt may be installed.

“This investigation highlights the risks of varying from procedures when performing maintenance tasks,” ATSB Director Transport Stuart Macleod said.

“It is important that, in all parts of the maintenance system, there is an awareness of human factors associated with completion of the task. An understanding of the demands associated with a task may help identify informal work practices that can then be aligned with the formal procedures.”

In response to this incident, the maintenance organisation has highlighted to maintenance staff the importance of following the safety instructions and warnings contained in the aircraft maintenance manual. Further, the maintenance organisation has reinforced procedures for maintenance activities – including task assessments, tooling, and task procedures.

Over the past three years, the ATSB has now investigated three separate incidents where maintenance engineers have inadvertently left lockout bolts installed in passenger aircraft engines after maintenance. The other two incidents, investigations AO-2018-064 and AO-2017-117, involved maintenance providers in Brisbane and Adelaide, respectively.

Read the report: Undetected engine thrust reverser deactivation involving Fokker F100, VH-NHA, Karratha Airport, Western Australia, on 27 December 2017

The ATSB is strongly encouraging pilots of experimental powered gliders to install fire protection between the engine compartment and cockpit following its investigation into a fatal accident where a modified jet-powered glider was destroyed by fire.

The call follows the ATSB’s investigation into a 21 January 2018 accident where a Schleicher ASH-25E glider which had been retrofitted with two small gas turbine engines caught fire not long after being launched from the Bathurst Gliding Club’s Piper’s Field airfield in central west NSW.

The experienced pilot had planned to conduct a solo cross-country flight, and eight minutes into the flight, the glider had climbed to about 2,200 feet in a thermal. Shortly after, the glider abruptly started to descend and track back towards the airfield, and witnesses reported seeing smoke or liquid trailing from behind the glider’s cockpit.

At about 1,100 feet, the pilot jettisoned the front-seat canopy but did not exit the glider, possibly due to incapacitation. Fire engulfed more of the rapidly descending glider’s fuselage before it collided with the ground in a nose-down attitude. The pilot was fatally injured, and the aircraft was destroyed.

The ATSB strongly encourages pilots of powered experimental gliders to install fire protection.

Due to the severity of the post-impact fire, the ATSB investigation could not determine the ignition source, but did establish that the glider’s cockpit and engine housing were not separated by a firewall.

“Pilots of powered experimental gliders are strongly encouraged to install fire protection between their aircraft cockpit and the engine housing,” said ATSB Director Transport Safety Stuart Macleod.

“The ability to exit a glider relies on avoiding incapacitation that can happen quickly in the event of in-flight fires.”

The accident glider had originally been fitted with a small Rotax piston engine driving a propeller mounted on a retractable pylon that allowed the glider to undertake self-sustaining flight (that is, maintaining level flight or initiating a climb, but not for launching). In 2010, the pilot had removed the original engine and propeller, replacing them with two small Titan AMT gas turbine engines for self-sustaining flight, with two 25-litre collapsible fuel cells installed into the wing root.

Once fitted with the jet engines, the glider was flown under an experimental type certificate. The Gliding Federation of Australia’s Manual of Standard Procedures states that flying experimental category gliders “is entirely on the basis of voluntary acceptance of risk by the persons who elect to do so".

Following the accident, the Gliding Federation of Australia published an Airworthiness Directive and an Airworthiness Advice Notice, both entitled Engine Compartment Fire Containment and Retardation, which provide guidance regarding fire safety.

The Airworthiness Directive requires all powered glider operators to inspect and repair fire retardant paint, fit ‘in case of engine fire’ cockpit placards and ensure there is no flammable material on the cockpit side of any firewalls.

Read the final report: Collision with terrain involving experimental ASH-25E glider, VH-GOA, 13 km west-north-west of Bathurst, New South Wales, on 21 January 2018

The flight crew of an Airbus A320 received a landing gear not down master warning while on approach to land at Ballina Byron Gateway Airport, New South Wales, due to an incorrect aircraft configuration following a go-around, a new ATSB investigation report details.

During the 18 May 2018 flight from Sydney, the A320 was conducting a visual approach to land on runway 24, with the first officer manually flying the aircraft. Manoeuvring to join the circuit on a left base, the captain recognised that the aircraft’s airspeed and altitude were both higher than a normal approach profile. However, due to circuit traffic, the captain elected to have the aircraft established on final approach before commanding a go-around.

The ATSB established that the flight crew did not follow their operator’s standard procedures during the go-around and subsequent visual circuit at 1,500 ft. In particular, the flaps remained at Flaps 3 rather than Flaps 1 during the circuit. This created a series of distractions leading to a non-standard aircraft configuration for a visual circuit. Limited use of available aircraft automation added to the flight crew’s workload.

Following standard procedures mitigates the risk of the selection of inappropriate auto-flight modes, unexpected developments, or confusion about roles or procedures can contribute to decisions and actions that increase the safety risk to the aircraft and its passengers.

During the downwind leg following the go-around, the flight crew did not select the landing gear down as they had commenced the configuration sequence for landing at the Flaps 3 setting. Furthermore, the flight crew incorrectly actioned the landing checklist, which prevented the incorrect configuration for landing being identified and corrected, the investigation established.

Consequently, on the second approach, at about 700 ft, a master warning was triggered because the landing gear had not been selected down. The flight crew then conducted a second go-around and landed without further incident on their third approach.

“This occurrence highlights the importance of adherence to standard operating procedures and correctly monitoring the aircraft’s approach and parameters to provide assurance a visual approach can be safely completed,” ATSB Director Transport Safety Director Dr Stuart Godley said.

“Following standard procedures mitigates the risk of the selection of inappropriate auto-flight modes, unexpected developments, or confusion about roles or procedures that can contribute to decisions and actions that increase the safety risk to the aircraft and its passengers.

The ATSB report notes that an incorrect aircraft configuration for landing is rarely the result of a single action or identifiable event.

“In this case a number of factors, such as distraction and limited use of aircraft automation, combined to result in the landing gear not being selected to down,” Dr Godley said.

“While highly undesirable, it should be noted that the aircraft’s warning system effectively alerted the flight crew to the problem and the crew responded promptly to the warning and initiated a second go-around.”

Dr Godley said the incident reinforced how unexpected events during approach and landing phases can substantially increase what is already a high flight crew workload.

Read the final report: Incorrect configuration for landing involving Airbus A320, VH-VQK, Ballina/Byron Gateway Airport, New South Wales, on 18 May 2018