The ATSB continues to emphasise the importance of maintaining effective communication at non-towered aerodromes, after an airspace-related incident involving a Beech 200 Kingair, and an Ag-Cat bi-plane at Swan Hill Aerodrome, Victoria.
The incident occurred on 21 November 2012, when the Kingair was approaching to land on runway 26 at Swan Hill. The pilot had broadcast the aircraft’s position and his intentions both when joining the circuit, and again when turning onto base leg. There was no response. When the Kingair was about 2.7 km from the runway 26 threshold, the pilot noticed a crop-spraying bi-plane, commencing a right descending turn ahead of him, approaching the same runway.
The pilot of the Kingair immediately made a radio broadcast but received no response. The pilot of the Kingair elected to continue the approach, and monitor the biplane carefully. Both aircraft landed safely.
Communication at non-towered aerodromes is an ongoing safety concern...
The ATSB investigation found that the biplane was not fitted with a radio. The pilot normally maintained a listening watch on a hand-held radio device. However, to avoid damage from the weather and chemicals he removed the hand-held radio when the aircraft was not flying. On this occasion, the pilot had inadvertently left the radio at home. The bi-plane pilot reported conducting a thorough visual check of the runway 26 approach as he joined the circuit, but did not see the Kingair.
Communication at non-towered aerodromes is an ongoing safety concern for the Australian Transport Safety Bureau. ATSB research has found that of the 709 safety occurrences at non-towered aerodromes during 2003–08, 388 were attributed to a breakdown in communication. Safety around non-towered aerodromes has been highlighted in the ATSB’s Safety Watch initiative.
ATSB investigators have found that the fatal aircraft accident in New South Wales in 2012 was the result of a situation in which many pilots have found themselves: flying into weather conditions that cannot be dealt with. This is a frequent accident risk that the ATSB has been drawing to the attention of Australia’s general aviation community.
The accident occurred on 4 June 2012, as the pilot flew a Cessna 182Q from Walgett to Mudgee. The pilot, the only person on board, was flying under the Visual Flight Rules (VFR), a set of regulations that dictated he could fly only under favourable weather conditions. He had taken off in good weather conditions, and climbed to 5,500 ft.
From 2006 to 2010, there were 72 such occurrences reported to us, and seven of those resulted in fatal accidents. Fourteen people were killed in these accidents.
During the flight, however, the cloud base lowered, and the pilot descended the aircraft to avoid flying in Instrument Meteorological Conditions (IMC). These are conditions where a pilot has limited visibility and will need to use aircraft instruments to fly safely. The aircraft descended until it was flying about 1,000 ft above flat terrain, either close to or in the cloud. While flying at that level the aircraft crashed into a rock face in mountainous terrain near Tooraweenah, NSW. The pilot died in the accident and the aircraft was destroyed.
“The issue of pilots who fly into IMC while operating under VFR is an ongoing concern to the ATSB,” said Martin Dolan, Chief Commissioner of the ATSB. “From 2006 to 2010, there were 72 such occurrences reported to us, and seven of those resulted in fatal accidents. Fourteen people were killed in these accidents. Essentially, about one in ten VFR into IMC events results in a fatal outcome.”
The ATSB has been working to educate pilots about the dangers surrounding VFR into IMC. A booklet providing examples and advice on the subject forms part of the ATSB’s well-received Avoidable Accidents series.
The ATSB’s Avoidable Accidents booklets, including Accidents involving Visual Flight Rules pilots in Instrument Meteorological Conditions, feature case studies on regularly occurring accidents that could have been prevented with good flight management and preparation. The booklets also provide helpful hints and strategies to help pilots stay safe when flying.
A collision between two freight trains at Dry Creek in South Australia has resulted in a rail operator amending its procedures for situations when trainee drivers are under supervision.
The accident occurred on 11 October 2011 as an empty ore train, was being driven by a driver-in-training with a co-driver supervising. As they proceeded on the interstate main line from Pelican Point to Rankin Dam (near Coober Pedy), the drivers were expecting a clear run without any stops through Dry Creek. The supervising driver was completing an administrative task and the driver-in-training, who was learning the route, became distracted by the headlights of a train ahead, believing it was in an adjoining yard. As a result, they missed an important caution signal, indicating that the train should stop at the next signal.
When the train was about 100 m from the signal, the driver noticed the stop signal. He used the emergency train brake, but passed the stop signal. The train travelled a further 218 m before colliding with the middle of the other train, loaded with grain, which was leaving the interstate main line and entering the adjoining rail yard.
The collision was at low speed and there was no injury to the crew of either train. There was significant damage to the crew cab of the lead locomotive of the ore train and to the grain wagons of the grain train.
Following the accident, the operator amended its procedures to clarify the role and responsibilities of a driver supervising a trainee, and introduced arrangements to inform the supervising driver of the trainee’s level of competency.
Robust procedures that systematically manage the supervision, training and assessment of drivers’ route knowledge are vital for ensuring competency and addressing risks.
A collision between an empty coal train and excavator at Maitland, NSW shows how clear communication of track workers’ location is vital to ensuring safe work on rail lines.
The accident occurred on 20 December 2011 and resulted in extensive damage to the excavator and some damage to the lead locomotive. Neither the crew nor the track workers were injured in the collision.
Maintenance work on the track had been authorised and safety measures designed to exclude rail traffic from the worksite had been put in place; however, the network controller did not confirm the exact location of the worksite before authorising access to the track for maintenance purposes. There were also communication protocol omissions between the network control and the worksite protection officer and a lack of coordination between interfacing network control officers.
As a result of the accident the track manager is reviewing safe working rules for Controlled Signal Block arrangements and will ensure that there is coordination between network controllers when a worksite affects more than one controller’s area of responsibility.
Safe work on railway tracks is a focus for the ATSB’s SafetyWatch initiative that stresses the importance of organisation and effective communication between controllers, crews and track workers.
In the last three decades, Australia has seen a significant growth in the number of amateur-built aeroplanes (aircraft built for personal use from an original design, established plans or kit, which are not entirely built and assembled in a factory). However, the safety record of amateur-built aircraft in Australia had not been robustly established.
What did this report do
The ATSB investigated the safety history of amateur-built aircraft in Australia through analysis of accident data held in the ATSB’s occurrence database from 1988 to 2010. Comparisons were made between accidents involving amateur-built aircraft and those involving similar factory-built aircraft to help identify whether the rate and types of accidents differed between these two groups of aircraft.
What the ATSB found
Amateur-built aircraft had an accident rate three times higher than comparable factory-built certified aircraft conducting similar flight operations between 1988 and 2010. The fatal and serious injury accident rate was over five times higher in amateur-built aircraft, in particular due to relatively more serious injury accidents.
The pilots of amateur-built aircraft involved in accidents were significantly more experienced overall than factory-built aircraft accident pilots. However, they were significantly less experienced on the aircraft type that they were flying at the time of the accident.
Over half of the accidents were precipitated by mechanical events, which were mainly complete or partial engine failures. Following the amateur-built phase one test period, mechanical failures were still significantly more common when compared with factory-built aircraft. A quarter of accidents were from loss of aircraft control. Structural failures were not common precursors in amateur-built aircraft.
Collision with terrain and forced landing accidents were more frequent in amateur-built aircraft. Collisions with terrain, hard landings, and runway excursions were more likely to result in a serious injury from an amateur-built aircraft accident than for factory-built accidents.
Safety message
Builders of amateur-built aircraft should select, install and maintain aircraft engines carefully as engine issues are the most likely reason why an accident will occur. Careful consideration to occupant protection at the time of building is also encouraged as serious injuries have been disproportionally more common.
Owners of amateur-built aircraft should ensure they have adequate training in the same type of aircraft before operating the aircraft they have built, or purchased second-hand.
Publication details
Publication number
AR-2007-043(2)
Investigation number
AR-2007-043(2)
Series number
2
Publication type
Research and Analysis Report
Publication mode
Aviation
Publication date
26/03/2013
Authors
Wilson, D. A., Taylor, R. P., Stanton, D. R., & Godley S. T.
A report released today by the ATSB identifies important opportunities to improve the safety of amateur-built aircraft in Australia.
Over the past three decades, amateur-built aircraft (aircraft built for personal use from an original design, established plans or kit, which are not entirely built and assembled in a factory) have become increasingly popular in Australia. This is the first detailed examination of their safety record. The ATSB’s research has identified key differences in the safety record of amateur-built aircraft when compared with similar factory-built aircraft and established an important baseline on which to improve safety in this growing sector of the aviation community.
“Between 1988 and 2010, there was a significant difference in the accident rates of amateur-built aircraft and comparable factory-built certified aircraft flying similar operations,” said Dr Stuart Godley, manager of the ATSB’s safety research section. “In fact, the amateur-built accident rate was three times higher.” In addition, the fatal and serious injury accident rate was over five times higher in amateur-built aircraft, in particular due to relatively more serious injury accidents.
Builders of amateur-built aircraft should select, install and maintain aircraft engines carefully as engine issues are the most likely reason for an accident to occur.
“Overall, the pilots of amateur-built aircraft are significantly more experienced as pilots,” said Dr Godley. “They’ve been flying for a long time, they know aircraft, and they want the challenge and intellectual satisfaction of building a customised aircraft. Some of the aircraft are one-offs—unique designs—but the majority are either built from plans or a prefabricated kit that they’ll buy and put together themselves.”
However, pilots involved in accidents in amateur-built aircraft are significantly less experienced on the aircraft type that they were flying at the time of the accident. More than half of all amateur-built aircraft accidents occur prior to the pilot accumulating 35 hours on the aircraft type. This included owner-builders and recent purchasers of second-hand amateur-built aircraft.
A significant finding is that over half of the accidents were precipitated by mechanical events, which were mainly complete or partial engine failures. Although common during the amateur-built phase one test period (first 25 to 40 hours), mechanical failures were also significantly more common after this test phase when compared with factory-built aircraft.
A quarter of accidents were from loss of aircraft control, generally due to aircraft handling issues involving pilots with limited experience on the aircraft type. However, structural failures were not common precursors in amateur-built aircraft accidents.
“We are encouraging owners of amateur-built aircraft to ensure that they have adequate training in the same type of aircraft before operating the aircraft they have built, or purchased second-hand,” said Dr Godley.
There are very few suitable aircraft available for type-training and instruction for amateur-built aircraft and the ATSB found that 20 per cent of pilots in these accidents had less than 10 hours experience on the aircraft type. Owners of amateur-built aircraft should ensure they have adequate training on type before operating new built or purchased aircraft.
Builders of amateur-built aircraft should select, install and maintain aircraft engines carefully as engine issues are the most likely reason for an accident to occur. Careful consideration to occupant protection at the time of building is also encouraged as serious injuries have been disproportionally more common.
Safe flight depends on reliable power. Despite the money and effort spent on ensuring aircraft engines are reliable, equally reliable systems are needed to ensure that engines always get the fuel they need.
This report discusses procedures that pilots can use before and during a flight to help them be absolutely sure they will have sufficient fuel to land at their destination aerodrome with reserve fuel intact. It does not discuss procedures to ensure fuel quality, such as checking all fuel drain valves for contaminants or using approved fuel, although these remain important. Nor does it discuss fuel system integrity measures, such as the maintenance of fuel filler cap seals.
The report will look at two main reasons why fuel stops getting to an engine during flight.
Fuel exhaustion happens when there is no useable fuel remaining to supply the engine(s).
Fuel starvation happens when the fuel supply to the engine(s) is interrupted although there is adequate fuel on board.
The more tanks you have to choose from, the greater the potential to make a mistake and to select the wrong fuel tank.
Key message
Accurate fuel management starts with knowing exactly how much fuel is being carried at the commencement of a flight. This is easy to know if the aircraft tanks are full, or filled to tabs. If the tanks are not filled to a known setting, then a different approach is needed to determine an accurate quantity of usable fuel.
Accurate fuel management also relies on a method of knowing how much fuel is being consumed. Many variables can influence the fuel flow, such as changed power settings, the use of non-standard fuel leaning techniques, or flying at different cruise levels to those planned. If they are not considered and appropriately managed then the pilot’s awareness of the remaining usable fuel may be diminished.
Keeping fuel supplied to the engines during flight relies on the pilot’s knowledge of the aircraft’s fuel supply system and being familiar and proficient in its use. Adhering to procedures, maintaining a record of the fuel selections during flight, and ensuring the appropriate tank selections are made before descending towards your destination will lessen the likelihood of fuel starvation at what may be a critical stage of the flight.
Conclusion
Fuel exhaustion is more likely to occur on flights when there is little flight fuel margin, that is, landing with just reserve fuel on board. In these circumstances, particular attention to detail in fuel management is warranted.
The chance of fuel exhaustion can be reduced by:
using more than one source of information to obtain consistent results about the fuel on board before flight
the use of a consistent procedure that is regularly checked to know the exact rate of fuel consumption
monitoring the flight to ensure that sufficient fuel will remain on board in the event of unplanned delays.
Fuel starvation usually happens when the selected tank is run dry. In addition to the factors relevant to fuel exhaustion, the chance of starvation can be further reduced by:
ensuring the pilot is fully familiar with the operation of the fuel system for both normal and abnormal operations
adhering to pre-flight procedures and checks to ensure the correct tank is selected before take-off and landing
using a fuel log during flight to provide a record of the fuel usage from each tank
selecting the appropriate tank before descending to the destination and ensuring that tank has adequate fuel for landing.
This publication is the first in a pilot education series by the Australian Transport Safety Bureau (ATSB) on avoidable accidents. In this report, we will focus on accidents involving unnecessary and unauthorised low flying; that is, flying lower than 1,000 ft (for a populous area) or 500 ft (for any other area) above ground level without approval from the Civil Aviation Safety Authority (CASA).
Between 1999 and 2008, there were 147 fatal accidents reported to the ATSB involving aerial work, flying training, private, business, sport and recreational flying in Australia. Of those fatal accidents, at least six were associated with unauthorised and unnecessary low flying. Those six accidents, along with a seventh non-fatal accident, presented here as case studies, were chosen by aviation safety investigators at the ATSB to highlight the inherent dangers of unauthorised low flying and to offer some lessons learnt from each case. It is hoped that these lessons learnt will help pilots make more accurate risk assessments and better decisions before electing to fly at low levels.
Before you decide to conduct low-level flying, ask yourself whether there is a legitimate or operational reason for you to do so.
At low altitudes, there are many obstacles to avoid and there is a lower margin for error. Recognising the risks and hazards of low-level flying, CASA requires pilots to receive special training and endorsements before they can legally conduct low-level flying. In the accidents described in this booklet, most of the pilots had neither of these, and none had a legitimate reason to be flying below 500 ft. Some legitimate reasons for flying at low level include aerial stock mustering, crop spraying, and firefighting operations. For most private pilots, there is generally no reason to fly at low levels, except during take-off and landing, conducting a forced or precautionary landing, or to avoid adverse weather conditions.
What is sad and unfortunate about the accidents described in the following case studies is that they were all avoidable.
These case studies serve as salient reminders of the risks associated with low-level flight. Out of the seven accidents documented in this report, only one had survivors. Low-level flying is inherently unsafe for a number of reasons, so it should be avoided at all costs when there is no operational reason to do it (regardless of whether you have been trained and/or approved to do so).
Flying at low level is unsafe because:
there are more obstacles to avoid, many of which are hard to see until it is too late (e.g. powerlines and birds)
pilots have a higher workload because there are more hazards to negotiate in the environment
there may be turbulence and windshear that pilots do not encounter at higher levels and
there is very little time to recover control of the aircraft if something goes wrong.
From the accidents described here, it is apparent that the two major hazards of low flying are wirestrikes and pilots’ reduced opportunity to recover their aircraft from a stall or loss of control.
It is important to keep in mind that powerlines also exist in remote areas where you least expect. For example, the pilots of the Stuart Highway accident probably did not expect powerlines in the remoteness of the Northern Territory, and the pilot of the Lake Eildon accident probably did not expect to encounter powerlines above the expanse of a large lake.
The effects of wirestrikes at low level are obvious — significant damage to the aircraft, usually leading to a loss of control and, because of the lower margin for recovery, subsequent impact with the ground or water. Pilots must keep in mind that not only do powerlines exist at low levels and in remote areas, they are also not easy to identify. Even against a clear blue sky, wires are difficult to spot for a number of reasons. Wires can oxidise to a blue/grey tinge and may blend into the background (ATSB, 2006), or the wire may be obscured by terrain. Single wires are difficult to detect from the air and can be encountered in the most unexpected places in rural areas. Even if a pilot has spotted a powerline, his or her ability to judge its distance from the aircraft can be distorted by optical illusions or a lack of nearby visual reference points.
Pre-flight assessment and planning is an important part of any flight. Make sure you have maps of your intended flight path with you when you fly, and study them before you get into your aircraft to identify any terrain, wire, or other obstacles that you need to avoid should operational circumstances necessitate flight at low level. If you have been trained and are qualified for low flying, and low flying is necessary, ensure that you conduct an aerial survey of the area from an appropriate height before you conduct any low flying.
Low-level flying also presents fewer opportunities to recover from a loss of control compared to flight at higher altitudes. It takes time to react and to regain control of an aircraft, and the closer to the ground you are, the less time and distance you have. Flying at low altitudes is not only risky when things are going right; it becomes downright perilous when things are going wrong.
Before you decide to conduct low-level flying, ask yourself whether there is a legitimate or operational reason for you to do so.
The Australian Transport Safety Bureau is drawing pilots’ attention to the effects of sun-glare when flying, after a Robinson R22 crashed into Lake Marradibbadibba in South Australia.
The accident occurred at about 1520 on 31 October 2012. The pilot (the only person on board) had commenced mustering in the helicopter on Innamincka Station at about 0730 that morning. Due to flying low over the sandy and swampy terrain, the helicopter’s windscreen became dirty, leading to poor visibility. During one break, the pilot tried to clean the windscreen with water but this did not improve visibility.
The accident demonstrates the effect that sun-glare can have when relying on visual cues.
The accident happened when the pilot conducted a low-level turn over the edge of the lake and experienced significant sun-glare from the water. Even though he was wearing sunglasses, the pilot became disoriented due to the sunlight and dirty windscreen. A few seconds later, the helicopter crashed into the surface of the lake and sank rapidly into 2.5 to 3 m of water.
The pilot was not wearing a helmet that day because it was damaged. Nevertheless, he escaped the accident without injury and swam to shore. The helicopter was seriously damaged.
The accident demonstrates the effect that sun-glare can have when relying on visual cues. In addition, although the pilot was uninjured as a result of this accident, previous ATSB investigations have shown the benefit of wearing a helmet.
The US Federal Aviation Administration (FAA) has conducted research into sunlight and its association with aviation accidents. A link to that report, along with more details of the accident can be found in the investigation report AO-2012-146.
The wheels-up landing of a Beech A36 is a good example of how pilot ‘distraction, pre-occupation, channelized attention or panic’ can lead to dangerous outcomes.
On 12 November 2012 a Beech A36 aircraft, VH-SQI (SQI) was conducting a fire inspection flight. On board were the pilot and one passenger. The aircraft took off from Meekatharra, WA bound for Kumarina where it conducted a 45-minute flight to observe nearby fires.
At about 0850 the pilot and passenger prepared to depart Kumarina for further inspection of fires in the area. During the take-off run, the forward cabin door, located next to the passenger, opened. The pilot elected to continue his take-off. The passenger was slightly alarmed by the opening of the door, but the pilot reassured him that it was fine and that they would return and land.
Just before landing the pilot realised that he had not done his pre-landing checks and had forgotten to lower the landing gear.
The pilot conducted a tighter and lower-than-normal circuit to expedite the landing, and decided to leave the aircraft in the take-off configuration to reduce his workload. He did, however, retract the landing gear. During the shorter circuit the pilot focused on locating a communications tower north of the runway within the circuit area. The pilot commented that he felt pressured and did not conduct his normal downwind and pre-landing checks as he believed the aircraft was already configured for landing.
Just before landing the pilot realised that he had not done his pre-landing checks and had forgotten to lower the landing gear. The plane landed with the wheels up and skidded to a halt about 200m down the runway. The pilot and passenger were uninjured, but the plane was substantially damaged.
The pilot reported that fatigue and workload may have contributed to the accident. He had flown the previous day and stayed at Meekathara overnight due to the approach of last light, and had started duty on the day of the accident at 0400 in the morning. The pilot also reported the workload of handling the abnormal situation, his concern about the passenger, a potential obstruction in the circuit, and his decision to rush the circuit all contributed to missing his downwind and final pre-landing checks and failure to lower and confirm the position of the landing gear.
