The main engine of the bulk carrier ID Integrity shut down and could not be restarted, leaving the ship drifting across the Coral Sea.

The ATSB is warning ship operators of the importance of heeding service advice from machinery manufacturers, and of maintaining all associated documentation. This reminder comes after a serious incident in the Coral Sea.

On 18 May 2012, ID Integrity was sailing from Shanghai, bound for Townsville, where it was going to load a cargo of sugar. While transiting the Coral Sea in heavy seas, the ship’s main engine shut down after its fuel pump reversing mechanism came free and jammed. This caused the camshaft to bend and slip in a drive coupling which resulted in the camshaft being out of timing and the engine unable to be restarted.

The ship’s master reported the situation to the Rescue Coordination Centre. The ship was in no immediate danger (about 100 miles to the east of Osprey Reef) and the engineers searched for the cause of the main engine stoppage. In the meantime, the ship’s managers negotiated a commercial towage agreement, and two tugs were dispatched to assist ID Integrity.

For around 52 hours, the ship drifted in a westerly direction towards the Australian coast and the Great Barrier Reef. Driven by the currents and the tides, it travelled more than 150 nautical miles. 

As ID Integrity approached Shark Reef, it became apparent that none of the tugs would reach the ship before it was likely to pass over the Reef. Other contingencies, including the use of the ship’s anchors, were considered. It was agreed that the master would de-ballast the ship to reduce its aft draught to 5.0 m, increasing the ship’s under keel clearance to the maximum possible. The minimum charted depth for Shark Reef is 8.1 m.

ID Integrity drifted across the southern end of Shark Reef in waters about 20 m deep, about 4 miles south of the charted 8.1 m depth. The ship was now about 60 miles from the eastern edge of the Great Barrier Reef Marine Park and was expected to close on it in less than 24 hours. 

At 0900 on 20 May, the tug PT Kotor rendezvoused with ID Integrity about 35 miles to the east of the Great Barrier Reef Marine Park. In the rough seas, it took about an hour to connect a tow line. The bulk carrier was towed to Cairns for repairs.

The ATSB found that the engine manufacturer had identified the need for owners and operators to check the fuel pump reversing mechanism for cracks and secureness and provided this advice in service letters. However, this advice had not been included in the engine manuals or planned maintenance system on board ID Integrity. As a result, over time and despite regular inspections, the system had deteriorated and cracks had developed in the mechanism undetected. This led to the failure of a fuel pump reversing link on 18 May. 

Read the final report: Breakdown and subsequent drift towards danger of the bulk carrier ID Integrity, Coral Sea, 18 to 23 May 2012

The ATSB is praising the crew of a Beechcraft B58 (Baron) for their handling of a nose landing gear collapse, which resulted in a wheels-up landing, without injury. 

The aircraft, with a pilot and co-pilot on board, took off from Hervey Bay bound for Toowoomba, Queensland on 3 April 2013. Shortly after take-off, as the landing gear was being retracted, the crew heard a loud bang. They detected a possible issue with the aircraft’s nose landing gear and began troubleshooting.

After unsuccessful attempts to diagnose the exact problem or to manually extend the nose landing gear, the crew decided to leave it extended and continued to fly to Toowoomba. After flying over the runway at Toowoomba, ground personnel advised the crew that the aircraft’s nose landing gear had extended but was not in the locked position. 

The crew took time to formulate a strategy for their landing, assigning responsibilities to each crew member and then rehearsed their plan.

The crew flew the aircraft to a training area to circle while emergency services were put in place for a wheels-up landing. During the next 45 minutes, they planned and rehearsed their landing in accordance with the aircraft’s flight manual. When advised that emergency services were in place, the crew elected to conduct a larger than normal circuit pattern to gain extra preparation time and so they would not feel rushed.  The crew landed the aircraft in accordance with their plan. As the main landing gear touched down the pilot selected fuel and mixture controls off, while the co-pilot reduced the throttle settings to idle and switched off the electrical system. When lowered, the aircraft’s nose slid along the runway. The aircraft stopped and the crew safely exited. As a precaution, the aircraft was covered with fire retardant foam but there was no fire. 

The aircraft had been built in the United States in 2012, was first registered in Australia on 29 January 2013 and had flown a total of 87 hours. An examination of the aircraft showed that the rod end of the nose landing gear forward retract rod had separated from the plunger tube on the nose landing gear plunger assembly. The examination suggested that there may have been a manufacturing issue. The nose landing gear of a second Baron aircraft built in 2012 with 127 hours service showed signs of a similar defect. 

The manufacturer determined that a required copper braze had not been placed in the plunger tube and this had led to the rod end separating from the plunger tube. It was found that the assembly of the rod-end retract assemblies had been outsourced to an external supplier in 2012. The external supplier had outsourced the brazing process. Eight other assemblies were found to be faulty, and the manufacturer issued a mandatory service bulletin. 

This incident highlights the benefits of flight crew using time to their advantage. The crew took time to formulate a strategy for their landing, assigning responsibilities to each crew member and then rehearsed their plan. This ensured they were well prepared, which ended in a safe outcome. 

Read the final report: Landing gear collapse involving a Hawker Beechcraft G58, VH-OMS, at Toowoomba Airport, Queensland, on 3 April 2013

An aircraft’s radio failure has shown the importance of maintaining communications and the need to alert Air Traffic Control of any problems as soon as possible.

On 5 April 2013, a Mitsubishi MU-2B aircraft with two pilots on board departed from Honiara in Solomon Islands, en route to Essendon, Victoria, with an intermediate stop at Townsville. On the way to Townsville, the pilot in command found that the aircraft’s high frequency (HF) radio was not working. Consequently, the crew relayed their aircraft’s position reports to Air Traffic Control (ATC) via other aircraft operating in the area.

As the aircraft drew closer to Townsville, the crew were able to communicate directly with ATC using the very high frequency (VHF) radio. The aircraft landed safely at Townsville and was refuelled. The pilot submitted a flight plan to Airservices Australia providing details on the aircraft’s planned route to Essendon. 

The ATSB emphasises the importance of alerting Air Traffic Control to any problems as soon as possible.

Shortly after take-off from Townsville, however, both the pilots and ATC discovered that the aircraft was transmitting carrier wave only (no voice communications could be heard). Townsville ATC offered the crew the option of returning to Townsville. The pilots could hear the transmissions made by Townsville ATC, but were unable to return as the fuel quantity in each wing tip tank was in excess of the maximum landing limitation and the aircraft was carrying additional fuel in the ferry tank. The pilots could not advise Townsville ATC of this as the aircraft’s very high frequency (VHF) radios were now inoperable. Consequently, the pilot elected to continue the flight as per the submitted flight plan.

The pilot attempted to fix the radio problem, but without success. ATC continued attempts to re-establish communications and left voice and text messages on both pilot’s mobile telephones and utilised two overflying aircraft. The Australian Search and Rescue (AusSAR) were also briefed on the situation. As the journey continued, Townsville ATC, Brisbane Centre ATC and Melbourne Centre ATC also continued attempts to establish communications with the crew.

When about 230 NM north of Essendon, communications with ATC were re-established. The crew had not been in normal communications with ATC for about 3 hours and 35 minutes. The aircraft landed safely.

A subsequent examination of the radio determined that water leakage from a small access door had corroded two main radio isolator breakers/switches, which resulted in the radio failure. The aircraft had been left outside for some time and subjected to tropical storms.

The ATSB emphasises the importance of alerting Air Traffic Control to any problems as soon as possible. This provides ATC with sufficient time to manage a situation, rather than having to react when an issue has developed into a major problem. In the event of a communications failure, it is important that pilots follow the appropriate procedure, and if radio communications cannot be re-established, consider utilising alternative methods such as mobile telephones.

Read the final report: Radio failure involving Mitsubishi MU-2B-60, N64MD, near Townsville Airport, Queensland, on 5 April 2013

The ATSB is urging aircraft owners and registration holders to review their maintenance schedules after a Cessna pilot’s control difficulties were found to be caused by component fractures and cracking.

The ATSB is strongly encouraging registration holders of class B aircraft to review their aircraft’s maintenance schedule to determine if it is the most appropriate for their aircraft and to ensure that it adequately provides for the continuing airworthiness for their aircraft.

This warning comes after a 12 September 2011 incident when the pilot of a Cessna 210 aircraft was conducting low-level aerial surveying near Bourke Aerodrome, New South Wales. After briefly encountering turbulence, he had difficulty making elevator control inputs and maintaining height. He was able, however, to land the aircraft safely with no injuries.

The ATSB has issued two safety recommendations to CASA as part of this investigation.

The ATSB investigation found that the control difficulties resulted directly from the fracture of the aircraft’s two horizontal stabiliser rear attachment brackets. The forward spar of the horizontal stabiliser was also extensively cracked. The fractures and cracking were all consistent with metal fatigue and typical of the damage that can be sustained by aircraft as they age. Many manufacturers have addressed the growing potential for this type of damage by introducing supplemental inspections to the principal aircraft maintenance requirements.

Some registration holders of class B aircraft, however, believed that their aircraft were exempt from the manufacturer’s supplemental inspections as long as the aircraft were maintained using the CASA maintenance schedule. This belief sprang from a misinterpretation of the Australian Civil Aviation Regulations 1988 (CAR). The CASA maintenance schedule did not make any specific reference to the incorporation of the manufacturer’s supplemental inspections, but it was a CAR requirement that all aircraft be maintained in accordance with approved maintenance data that, by definition, included those inspections.

The ATSB has issued two safety recommendations to CASA as part of this investigation. The first recommends that CASA proceed with its program of regulatory reform to ensure that all aircraft involved in general aviation operations are maintained using the most appropriate maintenance schedule for the aircraft type. The second is to ensure that the provisions of CAR Schedule 5 are clarified in relation to the incorporation of all relevant supplemental inspections specified for the aircraft type.

Read the final report: Flight control system event involving Cessna 210N, VH-JHF, 48 km west of Bourke Airport, New South Wales, on 12 September 2011

The ATSB is cautioning helicopter pilots about the dangers of ‘loss of tail rotor effectiveness’ following the forced landing and crash of a Bell 206B3 helicopter in Perth earlier this year. 

The accident occurred on 19 January 2013, while the helicopter was being used on an aerial filming task over hilly terrain. 

After hovering and manoeuvring at about 500 ft above the ground to allow the camera operator to record footage of a truck accident, the pilot conducted a final circuit to complete filming and depart the area. The pilot began the turn when the nose of the aircraft moved left, then suddenly and rapidly to the right as the helicopter yawed and quickly rotated five times.

The pilot regained some control close to the ground, but judged that a forced landing was inevitable. In an area with a number of obstacles, the pilot selected a clearing and managed to perform a low-impact landing. The slope that he landed on, however, resulted in the helicopter immediately rolling over with the engine still operating. Fortunately, it did not catch fire, a factor that can make all the difference for the survival of occupants in such accidents.

As well as understanding how LTE can occur, pilots should be familiar with the recommended recovery techniques and apply them immediately to the fullest extent possible in the situation.

The ATSB investigation found that when the pilot turned to the right to commence the circuit, the helicopter was exposed to a crosswind from the left while operating at an airspeed that left it susceptible to loss of tail rotor effectiveness (LTE) — a phenomenon which can send a helicopter moving in unexpected directions while temporarily robbing the pilot of control.

Aerial photography from most helicopters at relatively low airspeed and height, over hilly terrain in variable winds, is a challenging task with an inherent risk of LTE. In those circumstances, where visual cues can be misleading, pilot attention to airspeed, height and orientation to local wind is critically important. And, as in this occurrence, LTE can be preceded by momentary strong yaw in the opposite direction—a characteristic which is counter-intuitive and has the potential to be confusing for the pilot. There are recommended techniques for recovering from LTE.

The helicopter operator advised that as a result of the accident they conducted an internal investigation and implemented a number of safety actions in relation to LTE training and aerial work guidelines.

Read the final report: Loss of control and forced landing involving Bell 206B3 helicopter, VH-ZMN, 18 km north-east of Perth Airport, Western Australia, on 19 January 2013

An incident on 30 January 2013 involving a Fairchild Metro aircraft, flying freight from Melbourne to Launceston highlights the importance of correctly loading freight aircraft.

Before the flight, the pilot conducted his flight planning away from the aircraft and prepared a trim sheet to confirm the weight and balance information (The trim sheet or loading plan contains directions to the loaders to ensure that freight is correctly distributed on the aircraft so that it can remain within the centre of gravity range while in flight.) He supplied this to the freight company that prepared a loading plan for the aircraft.  When the pilot arrived at the aircraft the freight had been loaded, all cargo access doors had been closed and the cargo support strut (tail stand) had been removed. The pilot completed pre-flight checks and removed the wheel chocks and wing tip safety markers, before taking off.

While taking off, the pilot experienced difficulty achieving the correct trim. During the flight the auto-pilot struggled to maintain straight and level flight resulting in the aircraft ‘porpoising.’

While taking off, the pilot experienced difficulty achieving the correct trim. During the flight the auto-pilot struggled to maintain straight and level flight resulting in the aircraft ‘porpoising.’ The pilot conducted a normal landing in Launceston.

After landing, the pilot investigated the freight loaded in the nose of the aircraft and discovered that the locker only contained 35 kg of freight when it should have contained about 100 kg. The loading plan had indicated that there should be 100 kg in the nose locker but one of the loaders had removed about 70 kg and placed the cargo in the rear of the aircraft. This resulted in a rearward centre of gravity during the flight.

After investigating this incident, the operator found that:

• freight transferred from other flights had not been re-weighed,
• marked weight on freight pallets did not indicate whether it was gross or net
• the supervisor and ground personnel were not trained in loading procedures for the aircraft
• there was no strict control on the weight being loaded into each zone of the aircraft
• loaders were estimating freight weights going into each zone
• there were no procedures available for where to load cargo when the zone could no longer fit the cargo allocated to it.

As a result of this incident, the aircraft operator took action to issue a safety alert to all pilots requiring them to remove the cargo support strut and check the aircraft is loaded in accordance with the loading plan. They also undertook extensive improvements to documentation, training, audit, risk management, change management and project plans to improve ground handling and organisational safety.

Read the final report: Weight and balance event involving Fairchild SA-227AC, VH-UUO, Melbourne Airport, Victoria, on 30 January 2013

On 7 January 2013, a Piper PA-28 aircraft with a student pilot on board lost a wheel during take-off at Mangalore Airport.

After take-off an instructor on the ground noticed something trailing the aircraft and radioed the pilot to make a low-level pass so they could determine what the object was.

Following the low-level pass, the instructor noticed that the right main wheel and inner cylinder of the landing gear assembly had detached from the upper cylinder and was hanging off the brake line. After a second low-level pass they were seen to have detached completely.  

The aircraft touched down on the runway and slid off to the side, coming to rest on grass.

The instructor advised the student to hold over the airfield to burn off fuel and allow time for a plan to be devised. After several hours and with emergency services in attendance the student was instructed to make a normal approach. The aircraft touched down on the runway and slid off to the side, coming to rest on grass. The student was uninjured, but the aircraft was extensively damaged. 

An engineering examination revealed the lower torque link attachment bolt had failed via bending fatigue due to asymmetric loading (bending from one side). In September 2011, CASA had issued an Airworthiness Directive requiring inspection of torque links on all PA-28 aircraft every 100 hours, consistent with Piper Service Letter No 1199 and replacement with a new style link at 5000 hours. The aircraft had been fitted with the new style links; but there had been no requirement to inspect the torque link attachment bolts.

The operator has undertaken to replace all torque link attachment bolts during the next scheduled maintenance on all their Piper PA-28 aircraft. They will also treat any landings where a sideways load on the wheel assembly may have occurred with caution.

Read the final report: Landing gear separation involving Piper PA28, VH-JXR, Mangalore Airport, Victoria, on 7 January 2013

A Cessna 210M’s wheels-up landing at Broome shows how bad weather and changed plans can distract a pilot from flying safely, according to an ATSB investigation report.

On 23 February 2013, the Cessna was returning to Broome airport with a pilot and four passengers on board. The conditions were windy and wet with thunderstorms and rain moving through the area.  This meant the pilot had to alter the flight plan and flight path to avoid the poor weather.

While preparing for landing, the pilot reported selecting the landing gear down as part of his landing checks. A passenger later reported hearing what he believed to be the landing gear being lowered.

The aircraft landed on the runway with its landing gear retracted and skidded about 300 to 350 m on its underbelly.

Shortly before landing the pilot completed his final checks but did not look out the window to visually check that the landing gear was down. He reported, however, that he saw a green light that indicated the landing gear was down.

The aircraft landed on the runway with its landing gear retracted and skidded about 300 to 350 m on its underbelly. The pilot reported that the landing gear warning horn had not activated.

An insurance assessor found that the pilot had not extended the landing gear before landing and noted that the micro switch that activated the landing gear warning horn was set for a lower throttle setting than was used by the pilot. To compensate for the strong crosswind, the pilot operated the aircraft at a slightly higher throttle while coming into land.

An accident investigation report(Opens in a new tab/window) produced by the United Kingdom Air Accidents Investigation Branch provides further information on the link between the throttle settings and the activation of the gear warning horn on the Cessna 210.

Read the final report: Wheels up landing involving Cessna 210M, VH-PBV, at Broome Airport, Western Australia, on 23 February 2013

The crash of a Cessna 150 due to a stall is a reminder that pilots should take every opportunity to refresh their knowledge and skills. 

On the morning of 29 April 2012, the owner-pilot of a Cessna 150 was aerial stock mustering on a cattle station near Bourke, New South Wales. Some patches of fog had cleared, and the weather was fine and calm. 

After about 1.5 hours in the air, the pilot radioed stockmen on the ground to direct them to an area where cattle were not moving. The aircraft was seen circling over the area at about 100 ft and a short time later, in a steep descent towards the ground. The pilot died in the accident. 

The ATSB found that while manoeuvring at low level the pilot had inadvertently allowed the aircraft to aerodynamically stall, resulting in a high rate of descent and collision with the ground. 

The pilot did not hold a valid medical certificate and had not completed a flight review for a number of years. These both increased the risk of operating an aircraft, especially during aerial mustering operations. 

The accident highlights the importance of pilots undergoing a flight review at least every 2 years and practicing routine procedures under the supervision of instructors or approved training/check pilots.

Read the final report: Collision with terrain involving Cessna 150, VH-UWR, 55 km north-east of Bourke, New South Wales, on 29 April 2012

An accident where a radio failure prevented one pilot from warning another of a runway hazard highlights the importance of reliable communications.

On 22 February 2013, two Dromader aircraft were spraying cotton crops at Rumleigh (7km east-south-east of Brewarrina), NSW. One of the aircraft (TGY) was in the air while the other (TZJ) was being loaded with chemicals. TZY was about to take-off when its firebombing door unexpectedly released and spilled a large quantity of the chemical on the ground, contaminating the runway. (A firebombing door is attached to the aircraft’s hopper and enables a load to be released very quickly when it is used for fire suppression operations.)

The contamination created a layer of mud, which was not easily visible from the air. The pilot of TZJ tried unsuccessfully to contact TGY’s pilot to warn him of the hazard. The radio in TZJ had been working only intermittently since the previous day and had failed completely, so the broadcasts were not heard.

On landing, TGY crossed the contaminated area with one of its wheels and the mud caused it to slide and swing to the left. Eventually it pitched forward, and the propeller struck the ground. The pilot was not injured, and the aircraft sustained minor damage.

The pilot of TGY commented that it would be normal when they were unable to contact someone by UHF radio to send a text message by mobile phone or to place the mixers’ truck on the runway to provide an alert.

Having a reliable communications system or agreeing an alternative method of warning pilots of potential ground hazards will improve the efficiency and safety of an operation.

Read the final report: Loss of ground control involving a PZL-Mielec M18A Dromader, VH-TGY, 7 km east-south-east of Brewarrina Aerodrome (Rumleigh), New South Wales, on 22 February 2013