The landing gear collapse on a Raytheon B200 was due to the incorrect installation of a component, according to the ATSB investigation report. On 27 March 2013 a Raytheon B200 aircraft was being operated as an aero-medical flight between Darwin and Port Keats, NT. On board were the pilot and two flight nurses.

While preparing to land at Port Keats, the pilot selected the landing gear down. Only the nose landing gear (green) light illuminated. The unsafe landing gear (red) warning light remained illuminated for the left and right landing gear. The pilot cycled the landing gear and the landing gear circuit breaker tripped. The pilot reset the circuit breaker in accordance with the aircraft’s quick reference handbook, but it tripped again.

The pilot decided to return to Darwin and advised air traffic control (ATC) of the situation. During the flight the pilot completed the unsafe gear checklist including using the emergency gear extension system. While in the circuit area, another company pilot and Darwin ATC reported that the landing gear appeared to be down.

During landing, the right landing gear touched down first, but when the left wheel touched, the aircraft started to sink. The pilot transferred the weight to the right, shut down the left engine and feathered the propeller.  He then shut down the right engine and feathered the propeller. The left wing struck the runway and the aircraft skidded to a stop. The pilot and flight nurses exited the aircraft, without injury. The aircraft sustained substantial damage.

During landing, the right landing gear touched down first, but when the left wheel touched, the aircraft started to sink.

The left landing gear had been installed on the aircraft on 22 March 2013 and this was the first flight with the replaced gear. The operator found that a washer had not been installed in the assembly. CASA’s investigation found that there was no conclusive way to determine when the washer installation error had occurred. The manufacturer subsequently commented that the missing washer would not have caused the landing gear to fail to lock down. They believed it was more likely that a drag brace had either, not been installed, or had been rigged incorrectly, or that another landing gear assembly or maintenance error occurred, causing the circuit breaker to trip resulting in the accident.

Following the occurrence, the operator inspected all of its B200 aircraft and issued a safety bulletin to staff. The training and checking department were reviewing its proficiency checking for pilots in relation to this type of landing. The manufacturer is clarifying its maintenance manual.

Read the final report: Left main landing gear collapsed involving a Raytheon B200, VH-ZCO, Darwin Airport, Northern Territory, on 27 March 2013

A total power loss of a Mooney M20J at Canberra Airport highlights the importance for pilots of retaining currency in emergency procedures.

On 2 June 2013, the pilot conducted his pre-flight checks before a flight from Canberra to Albury. The pilot refuelled at Albury the day before and had noted that the bowser had been surging, turning on and off and pumping air. As it had rained the previous night, the pilot paid particular attention to conducting pre-flight fuel drains and checking for water, with none found.

During the take-off run, the pilot reported that all cockpit indications were normal, the aircraft attained full power and achieved the expected rotate speed followed by a positive rate of climb.

Seconds after the pilot retracted the landing gear at about 100 ft above the ground, the engine suddenly stopped. The pilot lowered the landing gear, switched fuel tanks and lowered the aircraft nose to increase airspeed.

During the take-off run, the pilot reported that all cockpit indications were normal, the aircraft attained full power and achieved the expected rotate speed followed by a positive rate of climb.

While the pilot was conducting emergency checks the aircraft descended and landed on the runway heavily on the left wing and landing gear, with the propeller striking the ground. The aircraft was substantially damaged, and the pilot sustained minor injuries.

Inspection of the aircraft’s engine after the accident revealed water in the left-wing fuel tank, fuel system and fuel injector lines. The pilot reported that he had contacted the Mooney Service Centre and had been advised that incorrect re-sealing of the M20 series aircraft fuel tanks could allow 1 to 2 litres of water to be retained in the wing, which could not be drained.

A pre-take-off briefing can remind the pilot of procedures during take-off at low altitude. Controlling the aircraft at low altitude and maintaining airspeed can reduce the severity of such incidents.

Read the final report: Total power loss involving a Mooney M20J, VH-NFP, at Canberra Airport, Australian Capital Territory, on 2 June 2013

On 11 November 2012 an Emirates A380 departed Sydney Airport for Dubai, United Arab Emirates.  While climbing through an altitude of approximately 9,000 feet the crew heard a loud bang accompanied by an engine No 3 exhaust gas temperature over-limit warning. Shortly, thereafter, the engine went through an uncommanded shutdown. The crew jettisoned fuel and returned to Sydney where the aircraft landed safely.

The investigation found that the increase in exhaust gas temperature and subsequent engine shutdown was the result of significant internal damage that had initiated within the high pressure turbine (HPT) module. The damage resulted from the effects of stage-2 nozzle distress likely caused by exposure to hotter than expected operating temperatures. The nozzle distress had led to eventual failure and separation into the gas flow path. Over the preceding weeks two other engines within the operator’s fleet had been similarly affected.

While the distress to the HPT was severe enough to result in an in-flight engine shutdown, the associated risks to the continuation of the flight were relatively low...

The engine had operated for a total of 15,318 hours and 1,876 flight cycles since new. Of that, 6,748 hours and 793 flight cycles had accumulated since the last workshop visit. At the time of the occurrence there were no outstanding items on the engine’s maintenance log. During the preceding flight of the aircraft, the manufacturer’s engine health and trend monitoring program had identified a performance trend shift with this particular engine and it was due to be inspected on return to the main base in Dubai.

The engine’s manufacturer, Engine Alliance had issued a service bulletin in June 2010 for the replacement of affected stage-2 nozzle segments with new more durable components during the next workshop visit when the HPT stage-2 was removed from the engine. Following this occurrence, another service bulletin was released on 6 December 2012, requiring the direct inspection of the nozzle segments that had not been replaced. The US Federal Aviation Administration also released an Airworthiness Directive that required inspection of the nozzle segments and their removal from service if distress was identified. 

While the distress to the HPT was severe enough to result in an in-flight engine shutdown, the associated risks to the continuation of the flight were relatively low, given the failure had been contained and the operators procedures were effective in managing the shutdown. This occurrence pointed to the value of real-time engine condition monitoring since advanced warning of engine degradation and efficiency loss allows inspection and corrective action to be taken before damage progresses to cause a shutdown. 

Read the final report: Engine failure involving Airbus A380, A6-EDA, near Sydney Airport, New South Wales, on 11 November 2012

The ATSB has warned rail transport operators of the importance of having robust systems to monitor and mitigate the risks to infrastructure from significant weather events. This warning comes after an accident near Roto in New South Wales which left a locomotive derailed and several of its trailing wagons damaged.

The accident occurred on 4 March 2012 when the train, consisting of two locomotives and 45 freight wagons, was travelling from Sydney to Perth. There had been a significant amount of rain in the region of Roto that morning—more than a 50-year rainfall intensity event. The Bureau of Meteorology had issued a severe weather warning for flash flooding for the district. As the train approached Roto, light rain was still falling. 

A mentor driver was supervising the trainee driver who had control of the train when he observed ‘white water’ flowing over the track ahead. Under the mentor’s instructions, the trainee applied the train brake. Then the mentor driver intervened directly: he moved over to the controls and applied full dynamic braking, and then the full independent and service brake as well. He then resumed his seat and instructed the trainee driver to brace, should the train not stop before entering the water. It didn’t. 

The flooding had caused scouring of the track formation, compromising its capacity to support the train.

As the train entered the water, the crew felt significant impacts with the locomotive hitting two distinct dips in the track. The second dip sent water up to cover the locomotive windscreen. The lead locomotive remained on track, but the trailing locomotive uncoupled and collided with the rear of the lead locomotive. No one was injured, although the locomotives, trailing wagons and the track were damaged.

The ATSB determined that runoff from the heavy rain had caused a flash flood event. The floodwater exceeded the capacity of a drainage culvert, which resulted in water overtopping the track formation with ballast and sub-grade scouring on either side of the culvert. The magnitude of that scouring meant that the track could not support the weight of train 7SP3 as it passed over the affected areas. The resulting deformation in the alignment of the track initiated the derailment. 

The ATSB also identified a safety issue with the track manager’s systems and operational procedures. They provided only limited information and guidance to network control staff in identifying and assessing the potential threat from the weather.

The track manager is now trialling the use of flood sensors at high-risk locations and has engaged the services of a third party to provide early warning information on potential high-risk weather events.

Read the final report: Derailment of freight train 7SP3, near Roto, New South Wales, on 4 March 2012

An amateur-built 1933 Pietenpol Air Camper collided with terrain after the landing gear caught the top wire of an electric fence.

The ATSB is warning pilots that when they are not operating from a designated landing area they need to ensure the area is suitable. This comes after an accident that occurred on 19 May 2013 near St Leonards, Tasmania. The pilot was taking a passenger on a scenic flight around Launceston, starting from a paddock behind his home. He had operated the aircraft from the paddock in the past, but not for a few years. A week before the accident, the pilot surveyed the area by car.

On surveying the accident site, the pilot realised that the aircraft’s landing gear had caught the top wire of an electric fence he had not noticed...

The aircraft was operating normally and became airborne at about 35 knots indicated airspeed. The pilot held the aircraft low, aiming to clear a fence at the end of the paddock. Nearing the fence, the pilot heard a loud noise and the nose of the aircraft jolted to the right.

The airspeed quickly decreased, as the pilot attempted to hold the wings level. After initially climbing to about 10 ft, the aircraft impacted the ground, breaking the landing gear. The aircraft skidded on its nose and then pitched over onto its back, breaking the propeller.

Both the pilot and the front seat passenger exited the aircraft without injury. On surveying the accident site, the pilot realised that the aircraft’s landing gear had caught the top wire of an electric fence he had not noticed, located a short distance before the paddock’s main fence.

Pilots need to assess proposed landing areas carefully, especially if they are not using a designated landing area. A thorough survey of the area to be used for take-off and landing should be completed immediately prior to use.

Read the final report: Collision with terrain involving a Pietenpol Air Camper, VH-ARW, 9 km north of Launceston, Tasmania, on 19 May 2013

Two airspace-related events around the same aeroplane landing area have shown the importance of pilots identifying potential hazards on their planned flight routes, and remaining focused on their surroundings.

Both incidents took place at Nagambie, Victoria. The first incident occurred on 3 May 2013, when the pilot of a Cessna 182 was conducting parachute operations over Nagambie. At the same time, the pilot of a Piper PA-28 aircraft was conducting a private flight from Mangalore to Bendigo, Victoria. He planned to fly from Mangalore to the Nagambie Township and then to Bendigo, to avoid a restricted area and parachute operations danger area.

In both occurrences, the pilots were operating on the see-and-avoid principle of air traffic safety.

A Danger Area is one in which dangerous activity (such as skydiving) takes place, so pilots entering that area need to take appropriate precautions. In contrast, restricted areas are areas of airspace into which pilots cannot fly without permission.

After completing the parachute drop, the Cessna conducted a circling descent, joining the base leg of the circuit and making a broadcast on the radio.

When about 6 NM to the west of the Nagambie Township, maintaining 2,500 ft, the pilot of the Piper saw the Cessna above, on descent, flying from left to right. The Piper pilot took action to avoid the Cessna.

As the pilot of the Cessna entered the danger area, at around 2,000 ft, he saw the Piper in his 12 o’clock position taking avoiding action. He banked his aircraft heavily to avoid the Piper. He estimated the aircraft came within 50 ft of each other.

The second incident occurred five days later, when the pilot of a Bell 206 helicopter was conducting a private flight from Mangalore to Echuca, Victoria, flying via the Nagambie Township to avoid the restricted area, maintaining 1,000 ft.

After passing near the Nagambie Lakes area, the pilot received a call on the radio from the drop zone safety officer on the ground at Nagambie advising that he had just flown over a parachuting landing area. At that time, five parachutists had just landed and six were still airborne.

In both occurrences, the pilots were operating on the see-and-avoid principle of air traffic safety. An ATSB research report, Limitations of the See-and-Avoid Principle, examines the potential risks that can arise in these scenarios.

Read the final report: Two airspace related events, at Nagambie (ALA), Victoria, on 3 and 8 May 2013

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 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