The ATSB’s investigation into foreign object damage involving an Airbus A320, VH-VGY at Auckland International Airport on 27 October 2017 found the aircraft’s right engine was damaged by metal debris from a clipboard left in the engine cowling.

After the loading of VH-VGY, the clipboard was left on the right engine cowling to protect it from the weather, with the intent of it being collected later. This did not happen. The presence of the clipboard was noticed during a ‘duty of care’ walk around but not reported.

ATSB Executive Director Transport Safety Nat Nagy says the incident highlights the need for everyone operating near the aircraft to take ownership of reporting foreign objects.

It is easy to think that someone else will report or remove a foreign object but that kind of thinking usually just increases the risk that it won’t get done.

“It is easy to think that someone else will report or remove a foreign object, but that kind of thinking usually just increases the risk that it won’t get done.” Mr Nagy said.

In this instance, staff recalled the need to collect the clipboard as VH-VGY was taxiing. Staff returned to where the aircraft was loaded, saw paper debris on the ground, and realised it had been left in the engine.

After the flight crew were notified, they checked their engine instruments and saw no abnormal indications. However, upon learning that sheared metal had also been found, the aircraft returned to Auckland. An engineering inspection found paper throughout the engine and minor damage to the fan blade and attrition liner.

Both Jetstar and the ground handling operator, Aerocare, have taken steps to educate staff of their reporting responsibilities around foreign objects. Jetstar has also updated their aircraft dispatch procedures to provide more detailed information about aircraft checks and responsibilities.

Read the final report: Foreign object damage involving Airbus A320, VH-VGY, Auckland International Airport, New Zealand, on 27 October 2017

The ATSB’s investigation into a collision with terrain of an amateur-built Sling 4 aircraft at Caloundra aerodrome, in Queensland, found that due the use of incorrect weight and balance data, the flight was conducted with the centre of gravity aft of its rear limit.

Before its flight on the morning of 12 August 2017, the pilot used the average or standard weights of each occupant to calculate the aircraft’s weight and balance with its electronic flight instrument system.

ATSB Executive Director Transport Safety Nat Nagy says that to reduce the risk of overloading the Civil Aviation Safety Authority recommends that load calculations for aircraft with less than seven seats should be based on the actual weight of occupants and baggage rather than standard or average weights.

Using actual weights for the load calculations would have prevented it operating with its centre of gravity aft of its rear limit.

“Using actual weights for the load calculations of the Sling 4 would have prevented it operating with its centre of gravity aft of its rear limit,” Mr Nagy said. “Operating like this meant it was less stable and more susceptible to an aerodynamic stall and harder to recover if a stall occurred.”

While descending, the Sling 4 deviated from its desired flight path. Attempts to continue the approach by manoeuvring the aircraft at low level and speed coupled with its loading outside of the permissible centre of gravity range reduced the remaining margins of controllable flight. 

The aircraft stalled and entered an incipient spin. Recovery from the stall was not possible and the aircraft collided with terrain. The fuselage fractured at the engine firewall and the engine was pushed rearward into the cabin. The aircraft was destroyed. The pilot and three passengers suffered serious injuries.

Further information: Guidance on the use of standard passenger and baggage weights for the calculation of aircraft weight and balance is available in the Civil Aviation Safety Authority’s advisory publication CAAP 235-1(1) Standard passenger and baggage weights(Opens in a new tab/window). Pilots can also refer to the United States Federal Aviation Administration publication Pilot’s Handbook of Aeronautical Knowledge Chapter ten, Weight and Balance(Opens in a new tab/window) for advice on correctly calculating aircraft weight and balance.

Read the final report: Collision with terrain involving The Airplane Factory Sling 4, VH-BEG, Caloundra Aerodrome, Queensland, on 12 August 2017

The ATSB’s investigation into the fuel exhaustion and forced landing of a Piper PA-28, registered VH-BDB (BDB), near Bankstown Airport, New South Wales, highlights the need for effective fuel management to avoid fuel starvation.

The accident occurred on 19 September 2017, when despite having enough fuel on board, the Piper aircraft had a loss of engine power that resulted in a forced landing, 15 km west-south-west of the airport. The loss of engine power was found to be the result of fuel starvation from the selection of a fuel tank with insufficient fuel to complete the flight.

ATSB Executive Director Transport Safety Nat Nagy says that accidents involving fuel mismanagement are an ongoing aviation safety concern.

“Each year, we receive more than 20 reports of fuel exhaustion or starvation,” Mr Nagy said.

You need to understand how the fuel system works on your aircraft, know how much fuel you have in each tank, and make sure you have the appropriate tank selected at all times.

In this occurrence, the pilot of BDB conducted a pre-flight inspection and believed the aircraft had full fuel on board and as the flight was only for 30-40 minutes did not intend to change the fuel tank selector during the flight.

As the aircraft returned to Bankstown and approached waypoint 2RN, the pilot noticed the engine was fluctuating. The pilot selected the electric fuel pump on, but the engine fluctuations became worse. The pilot then performed the engine failure immediate checks, but failed to change fuel tanks, and then carried out a forced landing. The pilot received minor injuries. The aircraft was substantially damaged.

Fuel exhaustion and starvation can occur during any phase of flight.  ATSB data shows that most reported occurrences have been in the cruise or in the descent, approach and landing phases of flight.

“You need to understand how the fuel system works on your aircraft, know how much fuel you have in each tank, and make sure you have the appropriate tank selected at all times,” Mr Nagy said. ‘To reduce the risk of a fuel starvation event when on descent, selecting the appropriate fuel tank during the pre-descent checks will avoid having to manage this during the higher workload period during approach to land.”

For information and procedures to avoid fuel starvation or exhaustion are available in the ATSB’s booklet Avoidable Accidents No.5 – Starved and exhausted: Fuel Management and aviation accidents(Opens in a new tab/window) as well as the Civil Aviation Safety Authority’s Civil Aviation Advisory Publication 234-1: Guidelines for aircraft fuel requirements.(Opens in a new tab/window)

Read the final report: Fuel starvation and forced landing involving Piper PA-28, VH-BDB, 15 km west-south-west of Bankstown Airport, New South Wales, on 19 September 2017

At 47 minutes past midnight, on 15 July 2017, the Spirit of Queensland tilt train was passing through Rockhampton on its way to Brisbane. Its route would take it through the intersection of Denison and William Streets, over a level crossing. The level crossing was a passive-type, with no active devices such as bells or flashing lights. Instead, there were posted signs alerting road drivers to the existence of the level crossing and the need to take care.

Five years earlier, a train had collided with a road vehicle at that intersection, and Queensland Rail and the Rockhampton Region Council had taken steps to resolve some minor issues with the sighting distance and signage.

Now, as the Spirit of Queensland approached the intersection, both of the train’s drivers identified that the intersection and its approaches were clear.

When the train crossed the intersection, however, they both heard a loud bang and there was jolt to the power car. The operating driver immediately applied the brakes and the train stopped about 40 metres later.

Upon alighting from the train, the driver found that the train had struck a road vehicle, a white Toyota Camry carrying four people inside. The car had driven in front of the train, and had been immediately struck on the driver’s side, causing it to spin and collide with the right-hand side of the train in the direction of travel.

Railway level crossing accidents have the potential to be catastrophic.

The three passengers of the car were treated for non-life-threatening injuries. The driver of the car and both train drivers were tested for alcohol and drugs. All tests returned zero readings.

Queensland Rail’s subsequent assessment of the site revealed no issues with sighting distance, signage, or design of the crossing.

According to the driver of the car, the car’s windows were open at the time of the incident, however, its occupants were actively engaged in conversation and none of them heard the train’s horn. The driver stated that the vehicle was slowed almost to a stop as it approached the intersection before accelerating to cross it. Neither the driver nor the passengers had noticed the train until immediately before the collision.

This incident is a reminder that all road vehicle drivers using railway level crossings equipped with passive controls need to be vigilant, observe road-warning signs, obey road rules and look out for trains.

ATSB Executive Director of Transport Safety Mr Nat Nagy said this was part of a familiar pattern in transport safety.

“Unfortunately, the ATSB has investigated a number of similar occurrences,” Mr Nagy said. “Last year alone, we initiated four investigations relating to level crossings. Thankfully, no one was killed this time, but that is not always the case.

“Railway level crossing accidents have the potential to be catastrophic. Taking the time to check and ensure that it’s absolutely safe to cross can make all the difference.”

Read the final report: Level crossing collision between Spirit of Queensland and a road vehicle, at Rockhampton, Queensland, on 15 July 2017

While experiencing high workloads, a flight crew member’s attention can channel or tunnel towards a single task, drawing or distracting their attention away from their other task demands.

An incident involving a JetGo registered Embraer ERJ-135 at Middlemount Airport in Queensland demonstrates the impact this can have during a part of a flight traditionally associated with the highest accidents rate—approach and landing.

On 8 August 2017, during the final approach leg, the aircraft descended below its desired approach path and landed prior to the selected aim point, resulting in its main landing gear tyres colliding with two runway threshold lights just before landing.

While there were no injuries or damage to the aircraft as a result of the incident, its descent below the desired approach path and its collision with terrain, however small, were cause for concern.

The impact of high workload can have a significance impact on any flight crew and it affects needs to be managed and monitored systematically...

Stuart Godley, Director Transport Safety at the ATSB says the impact of workload can be deceptive with an individual not realising it has increased until it has a reached a high level. “The best way of managing workload is to reduce the level of work demands and distractions,” said Godley. “However, in this incident the flight crew were managing a number of different factors in addition to the approach and landing.”

The ATSB investigation found the flight involved a captain under line training, who was operating a new aircraft type with new operating procedures. This was compounded by the high workload associated with the training, and the existing workload demands of approach and landing. In addition, the investigation found an absence of approach slope guidance at the Airport.

“The impact of high workload can have a significance impact on any flight crew and it affects needs to be managed and monitored systematically, especially for less experienced flight crews or those operating a new type of aircraft,” Godley said.

In response to the investigation, the operator has have advised the ATSB they have taken various proactive safety actions to reduce the risk of a similar incident in the future, such as line training flights to no longer operate to Middlemount Airport, and updating their flight crew operating manual (FCOM) to include material on runway visual illusions. The flight crew also underwent further training in approaches without a visual approach slope guidance.

The ATSB is encouraging operators and flight crews to consider the steps they can take to ensure they manage high and increased workloads so they can make appropriate decisions to ensure a safe landing.

“Making appropriate decisions and maintaining a stable approach profile is one of our key messages in our SafetyWatch list of concerns,” Godley said.

Read the final report: Collision with runway lighting involving Embraer ERJ-135, VH-JGB, Middlemount Airport, Queensland, on 8 August 2017

The ATSB has released its latest corporate plan, outlining the agency’s priorities, deliverables and challenges for the coming four years.

Greg Hood, Chief Commissioner and CEO of the ATSB, acknowledged that the plan was an important compass for the agency. “This is a substantial and outcome-focussed blueprint for the ATSB’s future,” said Mr Hood. “We are pursuing a significant reform agenda designed to enable better resource allocation and utilisation across the agency.”

In demonstrating increased effectiveness, the ATSB will become more selective in how it allocates resources towards investigating those accidents and serious incidents that have the greatest potential for safety learnings and enhancements. Concurrently, the ATSB will expand its capacity to improve transport safety outside of these traditional investigations, through safety issue investigations, through greater interaction with operators and regulators, with data and other intelligence in its possession, and through amplified communications, education and promotion.

“The ATSB’s greatest resource continues to be its people,” said Mr Hood. “Our transport safety investigators are world-class, and we are working hard to attract, develop, and retain the best people – people who have our shared values, passion and drive to improve transport safety for all Australians.”

Read the ATSB’s latest corporate plan.

The ATSB has today released an update into the tragic accident involving a B200 King Air aircraft that collided with a retail facility at Essendon Airport on 21 February this year. Sadly all four passengers and the pilot died in the accident.

ATSB Chief Commissioner Greg Hood said ATSB investigators have done an extensive amount of work to date.

“Investigators have gathered and assessed a large volume of evidence such as CCTV footage and witness statements. The team has also inspected the engines in close consultation with the manufacturer,” Mr Hood said.

“The aircraft’s fire-damaged CVR was retrieved and transported to the ATSB’s technical facilities in Canberra for examination and download.

“While the CVR was successfully downloaded, no audio from the accident flight was recorded. All the recovered audio was from a previous flight on 3 January 2017. The ATSB is examining the reasons for this.”

Mr Hood said that while the team is diligently assessing the physical and digital evidence, the considerable damage to the aircraft is presenting challenges.

“The extensive damage caused by the collision and post-impact fire has meant investigators are yet to determine a clear picture of the causal factors behind the accident and loss of life,” Mr Hood said.

“I offer my deepest sympathies to the families and loved ones of those on board the aircraft. Every effort is being made to determine the cause of this tragic accident.”

This update does not contain findings. The ATSB will present the findings of its investigation in the final report, due out in around 12 months. Further updates will be provided if significant information comes to hand.

If the ATSB identifies any safety issues during the course of the investigation, it will immediately bring them to the attention of relevant operators and authorities for safety action.

Read the preliminary report: Loss of control and collision with terrain involving B200 King Air, VH-ZCR at Essendon Airport, Victoria on 21 February 2017

As the range of products using batteries grows, the potential for in-flight issues increases.

On a recent flight from Beijing to Melbourne, a passenger was listening to music using a pair of her own battery-operated headphones.

About two hours into the flight while sleeping, the passenger heard a loud explosion. “As I went to turn around I felt burning on my face,” she said. “I just grabbed my face which caused the headphones to go around my neck.

“I continued to feel burning so I grabbed them off and threw them on the floor. They were sparking and had small amounts of fire.

“As I went to stamp my foot on them the flight attendants were already there with a bucket of water to pour on them. They put them into the bucket at the rear of the plane.” The battery and cover were both melted and stuck to the floor of the aircraft.

Flight attendants returned to check on her wellbeing. For the remainder of the flight, passengers endured the smell of melted plastic, burnt electronics and burnt hair. “People were coughing and choking the entire way home,” the passenger said.

The ATSB assessed that the batteries in the device likely caught on fire. The ATSB reminds passengers using battery-powered devices that:

• batteries should be kept in an approved stowage, unless in use
• spare batteries must be in your carry-on baggage NOT checked baggage
• if a passenger’s smart phone or other device has fallen into the seat gap, locate their device before moving powered seats
• if a passenger cannot locate their device, they should refrain from moving their seat and immediately contact a cabin crew member.

More information about Travelling safely with batteries and portable power packs(Opens in a new tab/window).

Other ATSB news stories and investigation reports about lithium-ion batteries:

• Aviation incident sparks lithium battery warning
• Personal electronic device fire in-flight involving Boeing 747
• Crew’s prompt in-flight response to smoking device.