An incident where a passenger jet took off at night without the crew noticing that the runway lights were off has illustrated the tricks that our minds can play on us.

At 11.27pm on 14 December 2012, the flight crew of a Jetstar Airbus A320 was preparing for take-off at Hobart Airport.

Outside tower hours, Hobart Airport operated as a non-towered, uncontrolled airport, operating on a common traffic advisory frequency. During that time, pilots could use radio transmissions to turn on the runway lights themselves.

As the flight crew prepared for take-off, they were under the impression that the runway lights were already on. The aircraft had several external lights, which illuminated the ground in front of the aircraft, and the Captain and First Officer saw several indicators that they took to mean that the lights were on. Both flight crew later commented that they had no difficulties maintaining directional control during the taxi and take-off roll, further noting that at no time did anything seem unusual or out of the ordinary.

...expectation bias is ‘seeing’ what you expect to see even when it is not there — in this case, runway lighting being on.

Runway and taxiway lighting serves many important functions for a departing aircraft. It can show the end of the runway, as well as necessary guidance for approach and landing if an emergency arises shortly after take-off. While the aircraft took off safely on this occasion, the incident highlights the potential hazards associated with change blindness, inattention blindness and expectation bias.

Change blindness occurs when a person does not notice that something is different about the visual environment relative to before the change. Research has shown that in some cases, quite dramatic changes are not detected, particularly if changes occur when the observer is not looking at the relevant part of the visual environment.

Inattention blindness occurs when a person does not notice an object which is visible, but unexpected, because their attention is engaged on another task. In this instance, the absence of airport lighting was noticeable, if looked for. However, the crew had an assumption or expectation that the lighting was on.

In simple terms, expectation bias is ‘seeing’ what you expect to see even when it is not there— in this case, runway lighting being on.

As a result of this occurrence, Jetstar Airways and Hobart International Airport have both taken action to ensure there is not a repeat of this incident.

Read the final report: Runway event involving Airbus A320, VH-JQG, at Hobart Airport, Tasmania, on 14 December 2012

Pilots are being urged to watch for wildlife hazards around the runway after an aircraft was substantially damaged from hitting a large bird and a bull.

On 24 March 2013, a Mooney M20J was about to land at Hedlow aeroplane landing area in Queensland.

Just before landing, one of the passengers pointed out two large birds that had taken flight from the long grass near the runway. The pilot then saw a ‘flash’ to the right of the aircraft and initiated a go-around.  One of the birds struck the left wing of the aircraft and the pilot reported that the aircraft yawed slightly left and the left wing dropped.

As the pilot reached over to raise the landing gear lever, the aircraft’s left wing struck a bull.

After regaining control and checking the instruments in the cockpit, the pilot looked outside again and noticed the aircraft had drifted to the right of the runway into an adjacent paddock. As the pilot reached over to raise the landing gear lever, the aircraft’s left wing struck a bull.

The aircraft then landed in the paddock without injury to the occupants. The aircraft was substantially damaged, and the bull was put down due to its injuries.

Following recent rains, the grass surrounding the airstrip had not been mowed and was knee-high. There was also a reasonable amount of low-lying water in the paddock next to the runway.

The pilot was familiar with the airstrip as his plane was hangered there, but observed that even if you are familiar with an airstrip, you should consider conducting a precautionary pass over the runway to alarm animals away from the area.  

The ATSB’s statistical report into wildlife and animal strikes 2002–2011 contains valuable background information for pilots and operators on the incidence of bird and wildlife strikes at Australian airports. Each year there are over 1,500 bird strikes reported.

Read the statistical report Australian aviation wildlife strike statistics: Bird and animal strikes 2002 to 2011

Read the final report: Wildlife strike involving Mooney M20J, VH-CYK, at Hedlow (ALA), Queensland, on 24 March 2013

An accident involving a Cessna that struck a tree and overturned during take-off shows why it’s vital for pilots to know how the performance limits of their aircraft.

On 9 February 2013, the Cessna 150F was taking off on the 11th fairway of the Mt Broughton Golf Course, NSW. The pilot had permission to land on the golf course and said he had previously landed and taken off there without incident. 

The pilot reported that the aircraft accelerated as normal, but when he realised it would not clear the trees at the end of the landing area, he elected to reject the take-off. The pilot reduced power and applied the brakes but ran out of clear space before the Cessna’s left wing hit a tree. The aircraft turned over and came to rest upside down. The pilot was uninjured, but the aircraft was badly damaged. 

The accident highlights the importance of pilots following the published performance data for their aircraft and knowing the performance requirements...

The pilot stated that the landing area had short grass that was wet with dew. He said that the aircraft had been fitted with a more powerful 160 horsepower engine (instead of the original 100 horsepower) and he did not know the available take-off distance at Mt Broughton.

An insurance assessor subsequently investigated the accident site and determined that the take-off length of the landing area was 1,180 feet. The performance charts for a standard Cessna 150F required 1,583 ft, however there was no available performance data for the 160 hp engine. 

The accident highlights the importance of pilots following the published performance data for their aircraft and knowing the performance requirements, physical characteristics and dimensions of the landing area that they intend to use. Other factors such as environmental conditions also need to be taken into account. 

Read the final report: Collision on ground involving a Cessna 150F aircraft, VH-ICE, 21 km south-west of Mittagong (ALA), New South Wales, on 9 February 2013

Following a stevedoring fatality, the ATSB has issued two safety advisory notices to stevedoring companies, highlighting the risks of break-bulk cargo toppling and of stevedore fatigue.

On 23 September 2012, a team of stevedores was loading aluminium ingots in the cargo holds of the general cargo ship Weaver Arrow, which was berthed in Newcastle, NSW. The ingots, each weighing about 23 kg, were strapped into 1-ton ‘packs’ of 44. Multiple packs (20 or 24) were strapped together to form a cargo unit or lift. 

The stevedore team leader was climbing down the ingot packs of a lift to work on a lower tier of the cargo when another member of the team saw the stack move. He yelled a warning, urging the team leader to jump. As the packs he was climbing down toppled, the team leader either jumped or fell to get clear. However, the adjacent stacks also toppled over in quick succession and packs from those crushed the team leader.

Other stevedores raised the alarm and tried to help the crushed man but he showed no signs of life. Paramedics and police officers arrived on the scene shortly afterwards and confirmed that the stevedore was dead.

No work should be undertaken in the vicinity of ingot stacks unless they have been secured
to prevent toppling.

The ATSB investigation found that it was common for some stevedores to climb up or down ingot packs to work on different cargo tiers instead of using the ladders provided. This was despite the fact that the ingot cargo units or lifts were inherently unstable and prone to toppling over. The stevedoring company’s procedure for loading aluminium products did not adequately address the risk of the cargo toppling over, and the implementation of basic precautions, such as using ladders to climb between cargo tiers, was not effectively monitored or enforced.

The ATSB also found that stevedores often worked extended hours, exposing the company’s operations to a level of fatigue-related risk that had not been assessed and treated.

In response, the stevedoring company, the company responsible for preparing ingot packs for loading, and the company managing Weaver Arrow have taken steps to make cargo handling—ingots in particular—safer. The ATSB has promulgated a safety message to industry that individual stacks of aluminium ingots and other similar break-bulk cargoes (whether or not strapped together for carriage on ships) should always be considered unstable and prone to toppling over. No work should be undertaken in the vicinity of ingot stacks unless they have been secured to prevent toppling. The ATSB has also recommended that Newcastle Stevedores address the issue of stevedore fatigue.

Unsafe marine work practices are a continuing concern in Australia. The ATSB has investigated several maritime accidents over the past few years that have resulted in serious injury or death. Through its SafetyWatch initiative, the ATSB is urging the maritime industry to give heightened attention to the ongoing safety issues facing marine workers.   

Read the final report: Stevedore fatality on board the general cargo ship Weaver Arrow, at Newcastle, New South Wales, on 23 September 2012

A crash landing following engine power loss shows why it’s important for pilots to maintain critical skills through regular flight reviews.

On the morning of 23 November 2012, the pilot of a Piper Cherokee Six, with two other owner-pilots on board, took off from Jandakot Airport, Western Australia.

About 700 ft above the ground, the engine suddenly lost power. The pilot immediately turned the aircraft towards one of the runways and focussed on flying the aircraft while the owner-pilot in the copilot seat conducted some of the troubleshooting checks. Unfortunately, the engine did not regain power.

The pilot had not completed a flight review in the 2 years before the accident, increasing the operational risks including responding to emergency situations.

Without enough height and speed to reach the runway, the pilot force landed the aircraft into wooded bushland about 150m short of the runway. The aircraft’s occupants escaped the accident with only one minor injury, but the aircraft was substantially damaged after hitting trees.

While the ATSB found no mechanical defects or fuel issues that would have affected the engine’s performance, investigators could not rule out carburettor icing as a contributing factor. No other likely contributing factors were identified.

It was also found that the pilot did not ensure all of the available procedures for an engine power loss and power-off landing were followed. This resulted in reduced gliding performance and a higher-than-necessary landing speed.

The pilot had not completed a flight review in the 2 years before the accident, increasing the operational risks including responding to emergency situations.

To effectively handle emergency situations, it is vital for pilots to use their established knowledge and skills, and ensure they always do a pre-take-off emergency briefing. As well, pilots should undertake regular flight reviews. By not complying with the periodic flight review requirements, the pilot missed an opportunity to maintain those critical skills.

Read the final report: Engine power loss involving Piper Cherokee Six, VH-TSZ, Jandakot Airport, Western Australia, on 23 November 2012

Pilot pressure and the layout of a non-towered aerodrome contributed to an airspace incident between a Beech 1900C and an Aerospatiale AS350 B2 helicopter, according to an ATSB investigation.

The incident occurred on 6 September 2012 at Newman Aerodrome in Western Australia. The Beech had made all required radio broadcasts and was on its take-off roll when the pilot saw the Aerospatiale helicopter unexpectedly enter the runway strip and take off parallel to the runway. The pilot of the Beech believed the paths of the two aircraft could cross if they both became airborne and, although his airplane was by this time moving at about 222 km/hr, he aborted the take-off. As the aircraft slowed, he saw the helicopter turn right and cross the runway about 200 m in front of the Beech and about 200 ft above ground level.

The pilot of the helicopter only became aware of the Beech when he heard the Beech’s co-pilot broadcasted that he was aborting the take-off. The Aerospatiale pilot made all required radio broadcasts but heard only one garbled transmission which may have been the Beech’s ‘rolling’ call.

New hangars had recently been built at Newman, which obscured the view from the GA apron to the threshold of the runway.

The pilot of the helicopter later explained that he had received word that a person at a survey site had been injured and required immediate evacuation. Feeling pressure to get to the injured person, he had turned right across the runway when the normal procedures required him to turn left.

At and around non-towered aerodromes, pilots are responsible for making themselves aware of nearby aircraft and maintaining separation. However, new hangars had recently been built at Newman, which obscured the view from the GA apron to the threshold of the runway. The hangars were also thought to be responsible for blocking radio transmissions between aircraft on the GA apron and those on the threshold of runway.

In response to this incident, the airfield operator is seeking to have a warning included in the aviation information publication for Newman. This warning describes the possible shielding effects from the aircraft hangars and requires adherence to specific procedures for helicopter arrivals and departures.

A study by the National Aeronautics and Space Administration (NASA) has found that perceived or actual pressure can contribute significantly to degradation in human performance and behaviour. The study recommended that pilots be particularly cautious if distraction or time pressure are encountered during the pre-flight or taxi phases of a flight.

The ATSB investigation report, AO-2012-118, contains links to useful resources on pilot pressure.

The SafetyWatch web resource also contains important information on safety in the vicinity of non-towered aerodromes.

The ATSB’s investigation into the engine failure of a Cirrus SR22 aircraft shows why it’s vital to always follow the aircraft manufacturer’s operating guidance. 

During a flight from Emerald, Queensland to Dubbo, NSW on 21 November 2012, the engine indications on the Cirrus SR22 were showing a gradual loss of oil pressure. Despite the pilot’s operating handbook advising the pilot to promptly land the aircraft to find the cause of the oil pressure loss, he decided to monitor the situation after contacting the maintenance organisation for advice. 

The oil pressure continued to drop and eventually the engine failed when the aircraft was 11 minutes from Dubbo, near Gilgandra. The pilot was not able to land at the Gilgandra airport and elected to deploy the ballistic parachute system fitted to the aircraft. The aircraft landed upright in a paddock and fortunately, the pilot and the passenger escaped with minor injuries. 

The pilot commented that the oil pressure indication dropped very gradually, giving a false sense of security. Three or four weeks previously, the aircraft’s engine temperature probe had failed. As the engine cylinder head temperature and oil temperature indications remained in the normal range, the pilot thought that the low oil pressure may have indicated another faulty probe. 

The aircraft had flown only around 4 hours following a 100 hour maintenance check. When the pilot conducted the pre-flight check for the accident flight, he noted that the oil level was below 5 quarts and 1 L of oil was added to the engine. The pilot’s operating handbook notes that the engine should not be operated with less than 6 quarts of oil and 7 quarts is recommended for extended flights.  

Read the final report: Engine failure involving a Cirrus SR22, VH-WYH, 7 km south of Gilgandra (ALA), New South Wales, on 21 November 2012

The ATSB is urging port managers and operators to consider all the risks associated with operations within their ports following the foundering of a ship at Christmas Island in 2012. 

On the morning of 8 January 2012, one of the permanent mooring lines holding the general cargo ship Tycoon in position at Flying Fish Cove, Christmas Island, came free from its anchor. As a result, the ship moved forward and closer to the nearby terminal rock face, eventually hitting the rock face as the weather and sea conditions deteriorated. 

Despite attempts to move it away, Tycoon continued to pound against the rock face. Eventually, the ship’s engine room began to flood through a tear in the hull. Shortly afterwards, the crew safely abandoned the ship.

The next day, Tycoon suffered a catastrophic failure of its hull and the contents of the ship’s number two cargo hold, about 260 tonnes of bagged phosphate, were exposed to the sea. The ship continued to be pounded by the sea and swell and, over the following months, it broke up. The wreck was eventually removed by salvors on 26 July 2012.

The ATSB investigation found that the shackle connecting the port’s mooring line to its anchor chain had failed. As well, Tycoon’s master did not advise shore authorities of his concern about the deteriorating conditions or that the mooring line had come free. He also did not make proper use of the ship’s main engine or mooring lines in an attempt to keep the ship in position after the mooring line came free. 

...the ship’s engine room began to flood through a tear in the hull.

In addition, it was found that there had been no risk assessment undertaken by successive port managers with respect to the use of the inner moorings and that there was little guidance provided to the masters of ships intending to moor in Flying Fish Cove. The managers of the port had not implemented an effective inspection and maintenance program and therefore were not aware of the deteriorated condition of the mooring line shackle.

As a result of the accident, the port operator has commenced replacing and upgrading the mooring equipment. They are also developing a Port Handbook which will be provided to the master of each ship and are facilitating safety training workshops that will be a forum through which the risks posed to the port and its operations can be assessed.

The ATSB investigation report advises port authorities to have procedures and contingency plans in place to deal with foreseeable emergencies. In addition, it is vital that there be effective maintenance and inspection regimes to ensure the good order of equipment and facilities.

Read the final report: Foundering of the general cargo ship Tycoon, Christmas Island, on 8 January 2012

The ATSB is warning of the dangers of improvising or modifying established procedures after a winching accident resulted in the death of a paramedic.

On Christmas Eve 2011, an emergency personal locator beacon was activated in the Budderoo National Park, about 16 km south-west of Wollongong, NSW. A rescue helicopter at Bankstown Airport was assigned to track to the beacon and departed, carrying a pilot, an air crewman, two paramedics and a doctor.

The crew located the beacon at a waterfall known as Bridal Veil Falls. A canyoner’s abseiling rope had failed, and he had fallen onto a rock ledge near the bottom of the falls, suffering serious injuries. 

The crew conducted an aerial reconnaissance of the area and assessed that, because of the terrain and vegetation, it would not be possible to winch personnel directly to the injured canyoner’s position and that vertical winch retrieval would similarly not be possible. Instead, the pilot landed at a nearby clear area and the crew devised a plan to access and retrieve the patient. 

As the helicopter moved toward the position to commence the retrieval, the paramedic and the patient were accidentally pulled from the ledge and fell several metres, hitting rocks.

One of the paramedics abseiled down to the patient, taking the end of a second rope (the tag line) with him. The other paramedic remained at the top of the waterfall, holding the other end of the line. The helicopter hovered over the top of the waterfall and lowered the winch hook, and the tag line was used to facilitate delivery of the hook to the ledge. Because the helicopter could not hover directly over the patient’s location, it hovered off to the side, and the idea was for the paramedic and the patient to move out under it, and use a stabilising rope attached to the terrain to ensure they did not swing.  

Due to fading light, and issues with the use of radios it was difficult for the parties in the helicopter and on the ground to communicate effectively. As the helicopter moved toward the position to commence the retrieval, the paramedic and the patient were accidentally pulled from the ledge and fell several metres, hitting rocks. The paramedic died from the impact. The patient was subsequently transported to hospital for treatment.

The ATSB investigation into the accident identified several safety issues relating to training and to the use of the helicopter’s lighting and radios. 

As a result, the Ambulance Service of New South Wales and the helicopter operator have taken a number of measures to improve the safety of their operations. These safety actions have included revising their procedures, expanding their training programs, and impressing upon their staff the importance of adhering to appropriate procedures. 

Rescue crews are frequently confronted with difficult situations and may be presented with rescue tasks they have not previously experienced. However, if they implement procedures that are not documented, or for which they have received no training, then it can be extremely difficult to identify hazards and manage the related risks.

Read the final report: Helicopter winching accident involving an Agusta Westland AW139, VH-SYZ, 16km west-south-west of Wollongong Airport, New South Wales, on 24 December 2011