A loss of separation between two Boeing 737s on reciprocal tracks demonstrates the importance of communication and coordination between air traffic controllers operating in separate, yet adjacent airspace, as well as the need for a clear understanding of the responsibility for separation assurance when operating without a shared traffic picture.

These are the key safety messages from the ATSB’s final investigation report into the 11 October 2018 incident, where a Qantas 737-800, registration VH-VZD, was on descent to Brisbane Airport through military-controlled airspace near Amberley Air Force Base, while a Virgin Australia 737-800, VH-YFW, which had departed Brisbane Airport, was approaching Amberley airspace on a reciprocal track. (Airservices Australia, which operates Australia’s civil air traffic management system, and the Royal Australian Air Force, which is responsible for controlling military airspace, such as around major air bases, currently operate separate air traffic management systems at Brisbane and Amberley. As a result, in this scenario traffic information had to be shared manually.)  

Due to thunderstorms in the area, the Virgin aircraft was flying air traffic control (ATC)-assigned radar headings, rather than using a procedural standard instrument departure. As the Virgin aircraft approached Amberley airspace, the Brisbane departures controller (operating from Airservices’ Brisbane terminal control unit at Brisbane Airport) provided an identification of the Virgin aircraft to the Amberley approach controller, who advised that there was an aircraft on an inbound air route. Brisbane replied that the Virgin aircraft would soon be turning right, and thus would avoid Amberley airspace; however when advised to turn right, the crew of the Virgin aircraft replied that due to the weather they wished to continue on their current heading for another 70 or 80 nautical miles.

It was around this time that the Virgin aircraft entered Amberley airspace without a hand‑off from Brisbane ATC and without instructions to the crew to change to Amberley frequency. Prior to this, the Brisbane terminal control unit had not advised Amberley ATC of a changed terminal control unit configuration. This delayed Amberley ATC in being able to contact the correct controller position at the Brisbane terminal control unit to inform them of the inbound aircraft, thus reducing the opportunity for Amberley ATC to resolve the impending conflict.

Once appropriate communication between Amberley and Brisbane ATC was established, the Virgin aircraft was transferred to the Amberley frequency, and the two aircraft were diverted away from each other.

The successful recovery of separation illustrates the effectiveness of the conflict resolution training received by air traffic controllers in loss of separation events.

The ATSB's investigation found the aircraft had incurred a vertical and lateral loss of separation with a minimum-recorded distance between the aircraft of 2.1 nautical miles horizontally and 650 feet vertically, respectively, where the required separation was 3 nautical miles horizontally or 1,000 feet vertically. (Both aircraft were fitted with traffic collision avoidance systems which would have assisted in providing separation instructions to their flight crews in the event ATC were unable to resolve the situation.)

“This investigation highlights the importance of clear communication and coordination between air traffic controllers operating in different, yet immediately adjacent airspace, and the need for a clear understanding of the responsibility for separation assurance, especially when operating without a shared traffic picture,” ATSB Director Transport Safety Dr Stuart Godley said.

As a result of the incident, both Brisbane and Amberley ATC have taken a number of steps to improve communication between their two systems.

“The ATSB welcomes the new dedicated communications pathway between the Amberley approach and Brisbane departures south positions, and the implementation of an airspace release that controls the risk that short notice deviations present across the two non-linked systems.”

Dr Godley also said the successful recovery of separation illustrates the effectiveness of the conflict resolution training received by air traffic controllers in loss of separation events.

Read the final report: Loss of separation involving Boeing 737 aircraft, VH-YFW and VH-VZD, near Amberley, Queensland, on 11 October 2018

An ATSB investigation into an accident where a Robinson R44 helicopter struck a powerline before colliding with the ground has highlighted the lack of readily available electricity network maps for pilots in Victoria, as well as the powerlines’ lack of aircraft markers.

The helicopter was conducting a private flight from a property near Mansfield, Victoria with a pilot and one passenger on board on 6 July 2019.

Before the flight, the pilot sought and obtained some information about hazards, including powerlines, from the property owner. However, the owner was not aware of a distribution powerline strung across the nearby valley with a span of 560 metres, and he could not see the wires from his property. The wires did not have aircraft markers and, in accordance with the relevant Australian Standard (AS 3891), did not require marking.

Additionally, and unlike some other states, readily usable Victorian electricity network maps were not available to assist the pilot’s planning.

As a result, the pilot’s pre-flight planning did not identify the powerline, which the helicopter struck 158 feet (48 metres) above the ground, shortly after take-off. The helicopter descended rapidly, travelling about 400 metres after the wirestrike before colliding with the ground in an upright position, and rolling over, resulting in serious injuries to the passenger and minor injuries to the pilot.

“In Victoria, electricity network information is not readily available to aid pilots during the flight-planning process,” ATSB Director Transport Safety Stuart Macleod said.

“Such information provides valuable safety information to aid pilots in planning flights, and assists the visual identification of hazards, such as wires and poles.”

It is good practice to always maintain a height of at least 500 feet above ground level.

The investigation also highlighted that when flying at low level, pilots should always be constantly scanning the terrain on either side of their flight path for poles and towers, and should avoid low flying unless it is necessary, Mr Macleod noted.

“The ability of pilots to detect powerlines depends on physical characteristics such as the spacing of power poles, the orientation of the wire, and the effect of weather conditions. Depending on the environmental conditions, powerlines may not be contrasted against the surrounding environment. In addition, the size of the wire and limitations of the eye can mean that it is actually impossible to see the wire,” Mr Macleod said.

“Therefore, it is good practice to always maintain a height of at least 500 feet above ground level except during take-off and landing.”

After the accident, local landowners advised the ATSB that the powerline was erected in the 1970s, and that an aircraft conducting aerial agriculture had struck it in the 1980s. They reported that following that past incident, orange plastic marker balls had been fitted to the wires, however, they had perished over time and not been replaced.

“Effective wire avoidance can be achieved using a combination of available wire location information; wire marking; and the avoidance of unnecessary low flying, especially flight below the height of surrounding higher terrain where wire spans may be present,” Mr Macleod reiterated.

Read the final report: Wirestrike and collision with terrain involving Robinson R44, VH-KCH, near Mansfield, Victoria, on 6 July 2019

The ATSB has issued a safety recommendation to AirAsia Indonesia calling for the airline to review its passenger safety briefing material to ensure instructions on how to activate passenger oxygen masks are clear and effective.

The formal recommendation follows an ATSB investigation into a pressurisation event on board one of the airline’s Airbus A320 aircraft about 30 minutes after departure from Perth on a scheduled passenger flight to Bali, on 15 October 2017.

During the climb, while passing through flight level* 340, the crew initiated an emergency descent to 10,000 feet in response to a master caution warning of a malfunction of the aircraft’s pressurisation system.

The captain made a passenger announcement for the emergency descent and manually deployed the passenger oxygen masks. During the emergency descent, some oxygen masks did not deploy or passengers felt they were not receiving oxygen. Consequently, some passengers then moved around the cabin to find a functioning oxygen mask unit. Passengers later surveyed by the ATSB recalled that the cabin crew shouted commands such as ‘BRACE’, ‘GET DOWN’ and ‘CRASH POSITION’, increasing their level of confusion and panic.

After reaching 10,000 feet, the flight crew announced the aircraft was at a safe altitude for oxygen masks to be removed. The aircraft landed safety at Perth Airport, with no injuries to passengers and crew, and no damage to the aircraft.

The ATSB’s subsequent investigation into the incident found that AirAsia Indonesia’s pre-flight safety briefing and safety information card did not include a clear instruction on how to activate the flow of oxygen from the passenger oxygen masks, and that the bag may not inflate when oxygen is flowing. This may have resulted in some passengers not understanding whether or not there was oxygen flowing in the mask.

Further, cabin crew provided additional commands to passengers that were inappropriate for a depressurisation, which had the potential to increase confusion in the cabin and likely increased the level of panic experienced by some passengers.

An important aspect of managing abnormal passenger responses is the cabin crew’s ability to recall and use appropriate standard commands.

ATSB Transport Safety Director Dr Stuart Godley said in an emergency, cabin crew are required to perform a safety leadership role for passengers.

“This incident highlights that an important aspect of managing abnormal passenger responses is the cabin crew’s ability to recall and use appropriate standard commands,” Dr Godley said.

“Passengers generally responded well when appropriate commands were used, but incorrect commands resulted in some confusion and panic.”

Dr Godley said that inclusion of information highlighting that oxygen is flowing through the mask even though the bag may not inflate will improve passengers' knowledge and reduce anxiety and their susceptibility to a hypoxia-related event.

“Cabin crew emergency procedures training that includes role-playing of the full range of expected passenger behaviour, including panic and confusion, can better prepare cabin crew when exposed to more complex real-world scenarios,” Dr Godley said.

The ATSB found the intermittent pressurisation system faults that led to the emergency descent were likely due to an intermittent incorrect calculation of cabin pressure by one of the aircraft’s two independent cabin pressure controllers (CPCs). During the incident, the affected CPC provided 12 intermittent fault messages before the crew began the emergency descent.

Read the final report: Pressurisation event involving Airbus A320, PK-AXD, 160 NM (300 km) north of Perth, Western Australia, on 15 October 2017 

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* At altitudes typically above 10,000 feet commercial aircraft operate to and are separated by ‘flight levels’. Flight levels are measured in units of 100 feet with the aircraft’s altimeter set to a standard air pressure of 1013hPa (rather than the local barometric air pressure). This ensures safe vertical separation between aircraft that might otherwise have altimeters set to different barometric air pressures. Aircraft set their altimeters based on local air pressure (known as QNH) below the ‘transitional level’, which in Australia is 10,000 feet.

Effective aircraft certification design requirements and flight crew training meant an Airbus A330 airliner landed without further incident after one of its engines ingested an engine cowling acoustic panel which failed during take-off, the ATSB investigation into the event notes.

During the 11 June 2017 occurrence, one of the three structural intake cowling acoustic panels of a China Eastern Airlines Airbus A330-200’s left engine separated and was ingested into the engine shortly after take-off from Sydney Airport’s runway 34 Left.

The flight crew effectively maintained control of the aircraft, continued the climb while reducing the thrust setting to idle, and declared a PAN PAN. The crew maintained an altitude of about 6,000 ft as they manoeuvred the aircraft to reduce its fuel load and address technical issues from the incident.

After 42 minutes, the aircraft landed safely at Sydney in an overweight configuration, where emergency services were on standby. Debris from the inlet cowling was later found strewn along the runway and the aircraft’s flight path.

Occurrences like this highlight how effective flight crew training ensures crews are able to effectively respond to any situation

“This event demonstrated the effectiveness of the certification design requirements and flight crew training to ensure continued flight despite effectively losing the power of one of two engines during a critical phase of flight,” said ATSB Director Transport Safety Dr Stuart Godley.

On landing, damage was identified to the inboard side outer inlet cowling skin including the number 1 and number 2 acoustic panels as well as the engine’s fan blades and cold stream duct. Minor airframe damage to the left wing trailing edge flaps, landing gear door, and left side of the horizontal stabiliser was also identified.

With the panel and cowling debris ingested into the engine, there was limited physical evidence available to ATSB investigators.

“Despite extensive testing conducted by the engine and cowling manufacturers, the reason for the failure could not be conclusively determined,” Dr Godley said.

“However, it was considered that the most likely reason for the failure was a localised disbond between the acoustic panel facing sheet and the honeycomb core.”

The ATSB found this was the fourth event where an inlet cowling acoustic panel manufactured by Bombardier Aerospace fitted to an Airbus A330 with Rolls-Royce Trent 700 engines had failed and was ingested. The first incident occurred in October 2006.

In 2014, in response to these earlier incidents, Rolls-Royce introduced a modification for the acoustic panels that doubled their density and adhesive contact area with the inlet cowlings. There have been no recorded failures of the redesigned panels. However, a number of pre-modified inlet cowlings are still in operation (including the one involved in this event).

As a result of this incident, Rolls-Royce issued an amended service bulletin which introduced a new inspection regime with 12-month (rather than 24-month) intervals as well as revised damage limits and highlighting how to conduct a ‘tap test’ to identify acoustic panel damage, including delamination.

Amendments to the service bulletin were also incorporated into a European Aviation Safety Agency airworthiness directive.

Read the final report: Engine cowling malfunction involving Airbus A330, B-6099, Sydney Kingsford Smith Airport, New South Wales, on 11 June 2017

The ATSB is calling for the implementation of improved tools and guidance for airshow display approvals and oversight following its investigation into a high profile fatal accident at an Australia Day air display in Perth in 2017.

A pilot and passenger were fatally injured when their Grumman G-73 Mallard amphibious aircraft aerodynamically stalled over the Swan River and collided with the water during the air display, which was part of the City of Perth’s Australia Day Skyworks event.

The ATSB’s investigation into the accident established that the Mallard was to conduct two circuits over Perth Water, ‘in company’ (that is, following behind at a prescribed distance) with a Cessna Caravan aircraft. The pilot of the Caravan had previous experience operating in this location, including participating in this air display. Following the Caravan was intended as a risk mitigator against the Mallard pilot’s unfamiliarity with display flying over the Swan River.

However, after conducting two passes in company, with both aircraft departing the display area, the pilot of the Mallard subsequently requested of, and received approval from, the air display ‘ringmaster’ to conduct a third pass. The aircraft then returned to the display area without the Caravan and in a manner contrary to the standard inbound procedure, requiring turns at higher bank angles and lower altitudes within a confined area to become established on the display path.

The ATSB investigation found that the aircraft stalled at an unrecoverable height. Had the Mallard re-entered the display area using the standard procedure for the air display, the manoeuvres required to position for the third pass would have been relatively benign with a significantly reduced risk of mishandling the aircraft. Further, the pilot’s decision to carry a passenger was also contrary to the requirements of the display approval and increased the severity of the outcome.

Having well-defined, transparent, and consistent processes for planning and approval of air displays assists in identifying risks and implementing effective mitigation strategies.

“Air displays have inherent and unique risks that everyone involved – pilots, organisers, and regulators – have responsibilities in addressing,” ATSB Executive Director Transport Safety Nat Nagy said.

“It is important that holders of these key positions have a thorough understanding of their role and responsibilities, to ensure adequate completion of safety critical tasks. Having well-defined, transparent, and consistent processes for planning and approval of air displays assists in identifying risks and implementing effective mitigation strategies.”

Mr Nagy said the investigation also highlighted that pilots can limit their exposure to risk by only participating in displays that are within their own and their aircraft’s capabilities and limitations.

“Pilots should not undertake any impromptu manoeuvres that have not been planned or practiced,” he noted.

Since the accident, CASA had independently published a revised manual of guidance for air displays in September 2017.

“The ATSB acknowledges the improvements to CASA’s manual of guidance for air displays and the associated forms,” Mr Nagy said. “But while these changes improve existing guidance, we consider that they only partially address the safety issue surrounding air display approval and oversight.”

Consequently, the ATSB has issued a formal safety recommendation to CASA calling for further improved air display approval and oversight tools and guidance, and enhanced procedures to ensure the suitability air display organisers, coordinators and participants.

Read the final report: Collision with water involving Grumman American Aviation Corp G-73, VH-CQA, 10 km west-south-west of Perth Airport, Western Australia, on 26 January 2017

The grounding of a bulk carrier which lost power while transiting a channel from the Port of Weipa highlighted gaps in the port’s risk plans, an ATSB investigation into the incident has found.

On 6 November 2017, the fully laden dry bulk carrier Orient Centaur was transiting the South Channel out of the Port of Weipa, Queensland, under the conduct of harbour pilots as part of a trial introduction of mini cape-size vessels to the port.

Just over an hour after departing from the wharf, the ship’s main engine shut down due to a loss of water from a cracked engine cooling component, and propulsion was lost. Without the ability to steer, the ship grounded on the northern batter of the channel. The stern then slowly swung across the channel and grounded on the southern batter, effectively blocking the channel.

The hazards associated with engine failure had been considered as part of the port’s risk assessment for the introduction of mini cape-sizes, and were to be mitigated by having tugs in attendance. Those hazards had only been considered, however, up to the point at which a ship had entered the South Channel. As a result, on the day of the occurrence, the tugs had been stood down and told to return to the berth after the Orient Centaur was steady in the South Channel.

Now, with the tide falling, there was a significant risk that the ship’s structural integrity would be compromised. The pilots estimated they had about 30 minutes to refloat the ship. A general call was issued to all tugs for assistance.

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Three tugs were mobilised to the assistance of the grounded Orient Centaur and, under the guidance of the harbour pilots, were successfully used to refloat the ship. Orient Centaur was subsequently towed out of the channel to an anchorage.

Surveys conducted over the following days identified that the ship had not sustained any damage.  

ATSB Director of Transport Safety Stuart Macleod said that the incident highlighted the value of comprehensive risk assessments.

“In pre-trial simulations, the risks associated with engine failure during departure were only considered up to when a ship had entered the channel,” Mr Macleod said.

Consequently, the tugs were not in attendance to assist if propulsion was lost. Additionally, the tug masters had not been trained in the specifics of escort towage, nor in emergency response.

“This occurrence highlights the importance of considering potential hazards from end to end in order to provide the best opportunity to manage safety risk,” Mr Macleod said.

In response to the occurrence, the Port of Weipa instituted new practices, with all departing ships over 200 m in length now having an escort tug made fast, from the wharf all the way through to the South Channel exit.

Separately, to address the engine failure issue, the ship’s managers have advised that cooling water is now tested weekly on board the ship, as well as every six months at a shore laboratory. In addition, only manufacturers’ original spares are to be used during maintenance.

Read the final report: Grounding of bulk carrier Orient Centaur, at Weipa, Queensland, on 6 November 2017

The ATSB is highlighting the importance of adhering to standard operating procedures following the release of a final investigation report into the hard landing of an ATR 72 airliner resulting from an unstable approach.

On 10 November 2017, ATR 72-212A VH-FVZ operating as Virgin Australia flight VA646 was arriving at Canberra Airport in conditions of light turbulence. On the flight deck were the captain (who was also a training captain), the first officer (who the captain had previously trained), and a check captain. The check captain was conducting a routine annual operational line check of the captain and a six-month operational line check of the first officer over four flights on the day. The occurrence flight was the last of these flights. In the main cabin were two cabin crew members and 67 passengers.

During the landing approach the first officer, who was the pilot flying, assessed that the aircraft was overshooting the desired approach profile. In response, at a height of 118 feet above the runway, he reduced engine power to idle, but this resulted in an abnormally high descent rate (in turboprop aircraft large propellers spinning rapidly in low pitch create a significant increase in drag).

The aircraft captain, who was the pilot monitoring, identified that power was incorrectly set, and twice called for an increase in power before subsequently intervening and increasing power himself. This intervention, however, occurred too late to arrest the high rate of descent.

Four seconds prior to touching down, the aircraft was descending at a rate of 784 feet/minute, already greater than the design limit of the undercarriage and above the normal descent rate for the approach of about 575 feet per minute. At that time, the aircraft was subjected to a significant change in the wind from a 10 knot headwind component to a 2 knot tailwind component. This resulted in a further loss of lift, and the captain later stated that he felt the aircraft drop out from under him.

Consequently the aircraft reached a recorded 928 feet per minute descent rate at touchdown, resulting in a 2.97 G hard landing on the main landing gear, tail skid and underside of the rear fuselage, resulting in substantial damage.

Unstable approaches continue to be a leading contributor to approach and landing accidents and runway excursions.

The aircraft subsequently required inspection of landing gear components, reskinning of sections of the fuselage underside, and replacement of the tail skid and a drain deflector mast before it could return to service.

“The continuation of the approach when a go-around should have been conducted allowed the subsequent conditions to develop, leading to the hard landing,” ATSB Executive Director Transport Safety Nat Nagy said.

“This occurrence demonstrates the importance of crews adhering to standard operating procedures and conducting a go-around when an approach becomes unstable.

“It also highlights the risks associated with incorrect handling of an approach to land, and the need for prompt and decisive action, as the available time to remedy an unstable approach situation is short.”

Mr Nagy noted that unstable approaches continue to be a leading contributor to approach and landing accidents and runway excursions.

Read the final report: Hard landing involving ATR 72, VH-FVZ, Canberra Airport, Australian Capital Territory, on 19 November 2017

The ATSB has issued safety recommendations to the United States Federal Aviation Administration and engine manufacturer Pratt & Whitney calling for them to maximise a modification that would prevent a component failure of the PW4170 series engine which powers some Airbus A330 airliners.

The recommendations follow an ATSB investigation into a 18 January 2018 incident where a Malaysia Airlines Airbus A330-300, which was operating a scheduled passenger flight from Sydney to Kuala Lumpur, Malaysia, diverted to Alice Springs due to a malfunctioning left engine.

Subsequent disassembly and inspection of the affected engine, a Pratt & Whitney PW4170, identified that, as a result of exposure to elevated temperatures, a segment of the third stage outer transition duct (OTD) had distorted and fractured. The large fractured section caused a blockage within the engine that created turbulent airflow, partially blocking a low pressure turbine vane inlet stage and causing an increase in exhaust gas temperature. That in turn led to low pressure turbine blade failure, high vibration and compressor stall/surge events.

If fleet-wide replacement is implemented, we expect this will have addressed the safety issue.

The ATSB investigation established that there has been a total of 16 similar events globally within the past four years, all attributed to the ‘Advantage 70’ increased thrust modification for the PW4000-100 series engine, including five involving Malaysia Airlines aircraft. The modification increased the engine outer duct gas path temperature, which led to the distortion and liberation of the outer transition duct segments.

Pratt & Whitney, which had ceased production of PW4000-100 series engines for the Airbus A330 in July 2017, has now redesigned the engine’s OTD to withstand higher temperatures. The newly designed hardware will be available for retrofit from this month (November 2019) and service bulletins will recommend installation of the new ducts at the operator’s discretion.

ATSB Director Transport Safety Stuart Macleod said that the ATSB welcomed the availability of the redesigned OTD

“This incident is an example of an engine modification that had undesirable consequences, and Pratt & Whitney has taken timely and significant safety action to redesign the outer transition duct,” Mr Macleod said.

However, the ATSB notes fitment of the ducts is not mandatory.

“We have issued safety recommendations to Pratt & Whitney and to the United States Federal Aviation Administration, urging them to take action to maximise the fitment of the improved components,” Mr Macleod said.

“If fleet-wide replacement is implemented, we expect this will address the safety issue.”

The ATSB is also reminding pilots that, when confronted with significantly abnormal indications, the safest course of action on most occasions is to discontinue the flight as soon as possible

“Recognising that the crew's response to the elevated temperature shortly after take-off was in accordance with the ECAM (electronic centralised aircraft monitoring) procedure, this occurrence highlights that significantly abnormal indications are often symptomatic of a developing problem,” Mr Macleod said.

“In such circumstances, crews should give serious consideration to returning and landing the aircraft rather than continuing with the flight.”

Read the final report: Engine malfunction involving Airbus Industrie A330-323, 9M-MTM, 37 km north of Curtin Airfield, Western Australia, on 18 January 2018

(Source: ATSB)

The ATSB is highlighting the importance of following procedures and applying best practice after two crewmen working aloft on a bulk carrier were seriously injured.

On 11 January 2018, bulk carrier Berge Daisetsu was berthed in Portland, Victoria. A team of six crewmembers were cleaning and painting the cargo hold under the supervision of the chief mate. While the vessel did not have portable scaffolding equipment or approved suspended access platforms for this task, the master discussed other options with the chief mate and bosun for how the upper sections of the hold could be tended to.

The decision was made to jury-rig a portable gangway into a work stage which could then be suspended from the cargo crane hook via slings. The ship’s crewmembers had several discussions, made plans and completed a risk assessment in accordance with the safety management system requirements. However, the equipment and machinery use was contrary to company policy and procedures.

As two crewmembers worked aloft on the platform suspended from the cargo crane, the crane’s block caught on the coaming and suddenly came free, sending an unexpected heavy shock into the platform. The two crewmembers were knocked over by the force of the sudden movement and landed heavily on their knees and lower body, causing serious injury.

The equipment and machinery were not suitable for the task, and their use made hazard identification difficult and exposed the workers to increased risk

The ATSB investigation found that the equipment and machinery were not suitable for the task, making hazard identification difficult, and exposed the workers to increased risk.

“This accident illustrates the consequence of deviating from accepted safety management procedures and industry best practice,” said ATSB Director Transport Safety Stuart Macleod.

“The use of machinery and equipment contrary to its intended purpose, makes hazard identification difficult and exposes those directly involved to significantly increased risk.”

The investigation also found that the fall arrest equipment used was incorrectly attached to the workers on the suspended platform. Consequently, had either of them fallen from the platform, the equipment would not have worked correctly, resulting in serious or fatal injuries.

As a result of this serious incident, Berge Bulk Maritime has completed the supply of approved working aloft equipment to its geared bulk carriers and is progressing modification of vessel cranes for personnel lifting. Specific working aloft and bulk carrier safety training has been conducted and made mandatory for crewmembers every two years.

Read the final report: Serious injury on board Berge Daisetsu, Portland, Victoria, on 11 January 2018

(Source: ATSB)

The ATSB is recommending the Civil Aviation Safety Authority (CASA) publish guidance for the inclusion of safe runway overrun areas at aeroplane landing areas (ALAs).

This formal Safety Recommendation to the aviation regulator stems from the ATSB’s investigation into the fatal accident of a Van’s RV-6A amateur-built aircraft at Somersby, near Gosford NSW, in March 2018. The investigation found an increased risk of occupant injury from a runway excursion at an ALA compared to certified aerodromes.

During landing, the aircraft initially touched down at about the runway’s midpoint at high speed, bounced several times and finally touched down when 125 metres from the runway end. The aircraft over-ran the runway end by 20 metres before impacting the side of a small watercourse, where the aircraft came to a complete stop. The pilot sustained serious injuries in the impact, and succumbed to his injuries two days later. There were no indications of an attempt of a go-around.

As part of the subsequent investigation, the ATSB compared the number of occupant injuries from runway excursions at ALAs with those at certified aerodromes. The analysis found the number of injuries after a runway excursion at an ALA was three times that at a certified aerodrome.

Between 2014 and 2018, there were 99 runway excursion occurrences at ALAs reported to the ATSB. Of these, 10 occurrences resulted in injury (10 per cent), compared with 250 runway excursion occurrences at certified or registered aerodromes, with eight occurrences resulting in injuries (3 per cent).

ALAs are not subject to CASA’s Manual of Standards for aerodromes, which mandates there should be at least an area 30 metres clear at the end of a runway at certified aerodromes to reduce the risk of damage and injury from a runway excursion.  

Instead, CASA’s Guidelines for Aeroplane Landing Areas 92-1(1) outlines considerations for ALA owners relating to obstacle clearance in the proximity of the runway surface area, but contains no specific advice for clear and flat runway overrun areas.

Should a runway excursion occur, obstacles in the overrun area at the end of an ALA runway can increase the risk of injuries to occupants and aircraft damage

“Where possible, ALA owners should consider the inclusion of a runway overrun area,” ATSB Transport Safety Director, Dr Stuart Godley said.

“Should a runway excursion occur at an ALA, obstacles at the end of the runway can increase the risk of occupant injury and aircraft damage.”

As a result of the investigation, the ATSB has issued CASA with a Safety Recommendation to publish guidance for the inclusion of a safe runway overrun area in their advisory publication for ALAs. This publication is a key guidance source for anyone building or maintaining an ALA.

“In this case, the presence of the watercourse at the end of the runway increased the risk of aircraft damage and serious occupant injury as the aircraft stopped significantly faster than it would have if the area had been cleared of obstacles,” Dr Godley said.

Nonetheless, this investigation once again highlights the importance of pilot preparedness to conduct a go-around if the landing criteria are not met or if there are indications of an unstable landing.

“The need for pilots to anticipate, plan and execute go-arounds remains a key safety message from the ATSB for the avoidance of runway excursions,” Dr Godley stressed.

The investigation did not identify any technical issues with the aircraft, including its engine and brakes.

Read the final report: Runway excursion and collision with terrain involving Van's RV-6A, VH-OAJ, Somersby, New South Wales, on 18 March 2018