Report highlights the importance of good flight crew communication to ensure a shared understanding of an aircraft’s system status.

• The captain under training misunderstood the command from the training captain, which led to the early rotation.

On 6 February 2012 the flight crew of an Airbus A320-232, registered VH-JQX and operating as Jetstar Flight 745, commenced take-off from runway 16R at Sydney Airport, New South Wales. The flight crew consisted of a training captain and a captain under training. The captain under training was occupying the left seat and conducting the duties of captain.

During take-off, one of the thrust levers was inadvertently moved forward of the required detent, which resulted in a thrust setting reversion to manual mode. The training captain identified the issue and initially made the standard calls to the captain under training to indicate the issue with the thrust lever.

The captain under training was transitioning from another aircraft type to the A320 and the manual thrust mode on the A320 was consistent with his experience of a normal take-off on the previous aircraft type.

The training captain made a call to indicate that the take-off should continue with maximum thrust selected, and the captain under training began rotating the aircraft below the required rotation speed. At about that time the training captain increased the thrust levers to the maximum thrust setting. After noting the aircraft’s airspeed was below the required rotation speed, the captain under training discontinued the rotation until a suitable airspeed was achieved before commencing the climb.

The ATSB found that the captain under training misunderstood the command from the training captain, which led to the early rotation. The training captain recognised the thrust lever asymmetry situation, however, the captain under training did not, and this resulted in a miscommunication that was not resolved effectively between the crew.

In addition, the captain under training was transitioning from another aircraft type to the A320 and the manual thrust mode on the A320 was consistent with his experience of a normal take-off on the previous aircraft type. Following this incident, Jetstar have incorporated a module into their simulator training for all pilots, covering incorrect thrust settings at take-off. They have also released a communication to pilots on the responsibilities of the pilot in command in operational events.  

Read the final report: Inadvertent thrust lever asymmetry during the take-off roll involving an Airbus A320, VH-JQX, Sydney Airport, New South Wales, on 6 February 2012

The trailing bogie on the 47th wagon of a freight train derailed after traversing the Carlton Parade level crossing at Port Augusta, SA. The wagon travelled over a second level crossing and re-railed itself when it entered a third level crossing about 1,300 m later.

• Railway track operators must assess and manage track defects thoroughly to avoid derailments.

The derailment of the 47th wagon of a freight train at Port Augusta, South Australia highlights the importance of rail transport operators carrying out thorough assessments and management of track conditions. 

On 6 May 2011, the trailing bogie on the 47th wagon of freight train 4PM6 derailed after traversing the Carlton Parade level crossing at Port Augusta. The wagon travelled over a second level crossing and re-railed itself when it entered a third level crossing about 1,300 m later. 

The defects had not been adequately assessed and controlled in accordance with the ARTC Track and Civil Code of Practice.

The train continued towards Adelaide before it was stopped at Winninowie after the network controller had been alerted that the train was emitting sparks and that the half-boom barriers remained down with warning devices continuing to operate at the two level crossings. 

In investigation report RO-2011-008, the ATSB found that multiple geometric rail defects needing urgent attention had been detected by a track geometry car inspection three months before the derailment. As a result, there was a 30 km/h temporary speed restriction (TSR) in force at the time. The defects had not been adequately assessed and controlled in accordance with the Australian Rail Track Corporation (ARTC) Track and Civil Code of Practice and the 30 km/h TSR was probably inadequate to minimise the risk of derailment. The ATSB also found that the track geometry defect exceedance reports did not contain fields to record the date and time as confirmation that field inspections had been carried out in accordance with the Code of Practice. 

As a result of the accident, the ARTC has, through its Alliance Partner Transfield Services, undertaken additional training on the ARTC Track and Civil Code of Practice. This includes the necessary responses to situations where there are multiple localised geometric defects. The ARTC is also developing an improved reporting format for data from geometry car measurements.

Read the final report: Derailment of bogie on freight train 4PM6, at Port Augusta, South Australia, on 6 May 2011

Pilots and operators need to inspect and maintain fuel cap seals to prevent the ingress of water into fuel tanks.

• An inspection of the aircraft wreckage found evidence of water in the right tip tank and airframe fuel filter bowl.

On September 2012, a Piper PA-32 was being operated on a private scenic flight near Yea, Victoria. About 5 minutes after departing, at about 1,000 feet above ground level, the pilot changed the fuel selection from the left main tank to the right tip tank. About 3 minutes later, when at about 800 ft the engine failed. The pilot changed the fuel selector back to the left main tank and placed the fuel mixture and throttle control full forward, but the engine did not respond. As a result, the pilot elected to conduct a forced landing.

The deterioration of fuel cap seals can allow the ingress of water into fuel tanks.

The pilot moved the throttle to the idle position and prepared for landing. During the landing the pilot noted that the engine power had been restored. The aircraft subsequently impacted two fences and sustained substantial damage.

Subsequent inspections found water contamination in the fuel tanks. Prior to the flight, the aircraft had been sitting idle for several months, fully fuelled, in a hangar. The pilot reported that he had washed the aircraft several months earlier and speculated that water may have entered the tank through the fuel cap.

The deterioration of fuel cap seals can allow the ingress of water into fuel tanks. CASA Airworthiness Bulletin (AWB 28-008) Water contamination of fuel because of failure of fuel filler cap contains information on inspecting fuel filler and caps and conducting pre-flight inspections of fuel filler/caps and fuel samples.

Read the final report: Engine failure involving Piper PA-32, VH-FAJ, near Yea, Victoria, on 22 September 2012

Two aircraft proximity events on the same day have reinforced the point that it is critical for pilots to broadcast and actively listen to the CTAF and maintain a vigilant lookout at all times.

• Pilot should not hesitate to call and clarify another aircraft’s position and intentions.
• it is critical for pilots to broadcast and actively listen to the CTAF and maintain a vigilant lookout at all times.

Two aircraft proximity events at Ballarat Airport on the same day have reinforced the point that it is critical for pilots to broadcast and actively listen to the Common Traffic Advisory Frequency (CTAF) and maintain a vigilant lookout at all times to enhance traffic and situation awareness. This is particularly important in a high traffic density environment.

The two incidents on 4 August 2012 involved Cessna 172S aircraft on convergent headings arriving at the same time at the airport. Both incidents were sighted by observers on the ground. In both cases one of the two pilots involved had been unaware that the incident had occurred.

A pilot should not hesitate to call and clarify the other aircraft’s position and intentions if there is any uncertainty.

In the first instance the aircraft passed in close proximity with about .2 NM lateral separation and 300ft vertical separation. In the second case, the distance reduced to 0.1NM laterally and 100ft vertically.

The pilots reported making CTAF calls but some differences between the pilots’ and observers’ recollections of events that could not be reconciled. Any radio broadcasts made by the pilots could not be verified as transmissions at Ballarat are not recorded. Ballarat airport experienced a reasonable amount of airport activity on that day.

ATSB reminds pilots that in accordance with Civil Aviation Advisory Publication 166-1 ‘…radio broadcasts should be made as necessary to avoid the risk of a collision or an airprox event. A pilot should not hesitate to call and clarify the other aircraft’s position and intentions if there is any uncertainty.’

Read the final report: Two aircraft proximity events at Ballarat Airport, Victoria, on 4 August 2012

A hard landing of a Cessna P206B at Monduran in Queensland is a reminder for pilots to conduct a go-around as soon as landing conditions appear unfavourable.

• A go-around is a standard manoeuvre when a pilot is not completely satisfied that the requirements are in place for a safe landing.
• The sooner a condition that warrants a go-around is recognised, the safer the manoeuvre will be.

On 29 September 2012, the aircraft departed Gympie on a private flight to Monduran, carrying the pilot and four passengers. During the landing at Monduran, the pilot noted the windsock was indicating gusty wind conditions but still decided to land.

A go-around is a standard manoeuvre when a pilot is not completely satisfied that the requirements are in place for a safe landing.

During the landing, at about 10 feet above the runway, the Cessna was struck by a significant wind gust. The aircraft bounced and the pilot applied a small amount of power in an attempt to regain control. The aircraft was then struck by a second, more intense, wind gust before stalling and touching down hard on the nose landing gear. The pilot maintained control and the aircraft came to a stop.

Although no one was injured in the incident, the aircraft’s propeller, nose landing gear, and lower engine cowls were damaged.

The ATSB recommends pilots conduct a go-around as soon as landing conditions appear unfavourable. A go-around is a standard manoeuvre when a pilot is not completely satisfied that the requirements are in place for a safe landing.

The need for a go-around may occur at any stage during the approach and landing. However, the most critical go-around is one initiated very close to the ground. Consequently, the sooner a condition that warrants a go-around is recognised, the safer the manoeuvre will be.

Read the final report: Hard landing involving Cessna P206B, VH-EGG, Monduran, Queensland, on 29 September 2012

The inadvertent retraction of an Aero Commander’s landing gear on the runway shows the ease with which habitual piloting actions can result in an error.

• During a landing roll, pilot inadvertently retracted the landing gear of an Aero Commander 500S.
• Pilots should take the time to identify any control lever before they action it.

On 21 August 2012, at about 1430 Eastern Standard Time, an Aero Commander 500S registered VH-YJS (YJS) departed Charleville Airport, Queensland for Brisbane Airport via, Roma, Dalby and Toowoomba on a freight only charter flight under the IFR. The pilot was the only person on board.

This resulted in the main gear collapsing and the aircraft sliding for a short distance before coming to rest on the runway.

During the landing roll the landing gear was inadvertently retracted, and the lower fuselage contacted the runway. The pilot exited the aircraft without injury however the lower fuselage of the aircraft was damaged.

A manual safe pin was incorporated as a design feature to prevent inadvertent retraction of the landing gear. However, operation of the gear lever and safe pin together had become an automatic response by the pilot and the effectiveness of the safe pin as a countermeasure reduced. Pilots are reminded to positively identify any control lever before actioning.

The Aero Commander 500S departed Charleville Airport in Queensland bound for Brisbane airport via Toowoomba on a freight charter flight. About 300 m into the landing roll at Toowoomba airport, the pilot inadvertently retracted the landing gear while attempting to retract the aircraft’s wing flaps. This resulted in the main gear collapsing and the aircraft sliding for a short distance before coming to rest on the runway. The pilot, the only person on board, survived the accident without injury.

A manual ‘safe’ pin had been incorporated as a design feature to prevent inadvertent retraction of the landing gear. However, the pilot’s operation of the gear level and safe pin at the same time had become an automatic action, reducing the effectiveness of the safe pin as a countermeasure.

As a result of this accident, the operator has taken a number of safety actions, including modifying the landing gear control, and implementing random flight checks by check and training captains. In addition, the ATSB is encouraging pilots to take the time to identify any control lever positively before they action it.

Read the final report: Inadvertent landing gear retraction involving Aero Commander 500-S, VH-YJS, Toowoomba Airport, Queensland, on 21 August 2012, which contains useful information on skill-based errors and muscle memory.

The ATSB is highlighting the importance of carrying personal communication equipment and taking extreme care when refuelling aircraft. This comes after an accident where a helicopter was destroyed by fire and the two occupants were left without any survival gear or communications equipment.

• When conducting remote area aerial operations, always carry personal communications equipment.
• Take appropriate care when refuelling aircraft.
• In emergency or abnormal situations, it is important to make decisions that reduce the level of risk to the safety of the aircraft and its occupants.

On 19 June 2012, the helicopter, a Eurocopter AS-350BA, was 15 minutes into a flight from Ceduna to Border Village, South Australia when the pilot and passenger smelt fumes in the cockpit. Shortly after smelling the fumes, the pilot conducted an emergency landing in a remote area about 50 km west of Ceduna. Once on the ground, the passenger exited the helicopter and noticed smoke and fire coming from the rear cargo compartment. The pilot and passenger escaped without injury.

Neither the pilot nor the passenger was carrying a satellite phone or a personal emergency radio beacon.

The helicopter was fitted with an Emergency Locator Transmitter which could have transmitted their position to Search and Rescue. However, it did not activate and was destroyed in the fire. Neither the pilot nor the passenger was carrying a satellite phone or a personal emergency radio beacon (EPIRB). Fortunately, they were rescued several hours later.

The investigation could not determine the cause of the fire but an earlier spillage during refuelling may have provided an initial fuel source for the fire. The operator has since ensured that all operations will have the appropriate equipment, and has amended the procedures for carrying large containers of fuel.

This incident also highlights the importance of making decisions to reduce the level of risk to the safety of the aircraft and its occupants in emergency or abnormal situations.

Read the final report: In-flight fire involving Eurocopter, AS 350BA, VH-HEB, 51 km west of Ceduna, South Australia, on 19 June 2012

The ATSB is urging pilots to be diligent in the performance of checklist items during all stages of flight. This reminder follows an incident where a Piper Seneca experienced fuel starvation while cruising at 9,000 ft above sea level. 

• Pilots are reminded to be diligent in the performance of checklist items during all stages of flight as they are there to capture errors made before and during flight. 
• Checklists are the most readily available way to manage risks of errors and omissions.

On 31 August 2012, the aircraft departed Hobart Airport for Bankstown on a private flight. At about 19 km south of Nowra, the pilot (who was the only person on board) heard a bang and the left engine stopped with the right engine stopping shortly after. The pilot immediately feathered the propellers, declared a PAN and started looking for a suitable area to land. He proceeded through the memory items on the emergency checklist. While performing the emergency checklist, the pilot discovered that the right fuel selector was in the cross-feed position and the left fuel tank had run out of fuel. He repositioned the fuel selectors and restarted both engines.

At the time of the engine restart, the aircraft had descended to 4,000 ft. The pilot advised air traffic control that both engines were now running and that he would continue to Bankstown as planned.

On landing at Bankstown, the aircraft had a significant lateral imbalance, as the left wing tank was empty and the right wing tank was almost full. As a result, the aircraft departed the runway after landing. The pilot regained control and the aircraft taxied to the parking area without further incident. The aircraft was not damaged, and the pilot was not injured.

The pilot had been accustomed to being assisted on flights by his wife, who would hold the checklist and read out the items. On this flight, however, she was not with him. Checklists are the most readily available means of risk management against errors and omissions.

Read the final report: Fuel starvation involving Piper Seneca, VH-BTW, 19 km south of Nowra Airport, New South Wales, on 31 August 2012

The ATSB investigation into the fatal accident at Canley Vale, New South Wales (NSW) on 15 June 2010 has yielded important safety messages for pilots when flying twin-engined aircraft with one engine shut down: 

• The optimal speed must be flown and the maximum continuous power selected on the operative engine to achieve the aircraft’s published one engine inoperative performance.
• It is important to verify the aircraft’s performance before conducting a descent.
• Pilots should use the appropriate PAN or MAYDAY phraseology when advising Air Traffic Control (ATC) of non-normal or emergency situations. 

The accident occurred during a flight from Bankstown Airport, NSW to Archerfield Airport in Queensland. The Piper PA-31P-350 Mojave, with a pilot and a flight nurse on board, was being positioned to Archerfield for a medical patient transfer flight from Archerfield to Albury, NSW. Twelve minutes after taking off, the pilot reported to ATC that he was turning the aircraft around as he was having ‘a few problems.’ He shut one engine down due to an unspecified ‘engine issue.’

The Civil Aviation Safety Authority has since started a project to amend advisory material relating to multi-engine aircraft training and operations to include guidance information about engine problems encountered during the climb and cruise phases of flight.

Over the next 13 minutes, as the situation worsened, the pilot and ATC maintained communications, attempting to work out the best options. The pilot advised that he would have to land the aircraft on a road. Although clearly in an emergency situation, the pilot did not use the PAN or MAYDAY terminology in his communications.

At about 0806 Eastern Standard Time, the aircraft collided with a powerline support pole at Canley Vale. Both occupants were fatally injured and the aircraft was destroyed by the impact forces and an intense post-impact fire.

The Australian Transport Safety Bureau (ATSB) commenced an in-depth investigation immediately. The investigators constructed a detailed chronology, using information from recordings of radio communication between the pilot and ATC, recordings of radar data, ATC documentation, meteorological data and post-accident witness interviews. The aircraft’s position and altitude were obtained from radar data recordings and plotted on an extract of the Sydney Visual Terminal Chart.

The fact that the pilot had not given much detail about the nature of the problems he was experiencing created a challenge for the investigation. Examination of the engines, propellers and governors and other aircraft components found no evidence of any pre-impact faults. In order to understand the engine performance during the occurrence, the ATSB conducted a spectral analysis of the pilot’s radio transmissions. The changes in frequencies of signals from the aircraft’s propellers and alternators throughout the transmissions gave valuable indications about the operation of the engines. The investigator's discovered that, when the pilot reported to ATC that he was turning the aircraft around, there had been surging of an engine which was consistent with uneven fuel distribution to the cylinders.

It was found that, following the shutdown of the right engine, the aircraft’s airspeed and rate of descent were not optimised for flight with one inoperative engine. In addition, the spectral analysis indicated it was unlikely that the left engine was being operated at maximum continuous power as the aircraft descended. As a result, the aircraft descended to a low altitude over a suburban area and the pilot was then unable to maintain level flight, which led to the collision with terrain. 

The Civil Aviation Safety Authority has since started a project to amend advisory material relating to multi-engine aircraft training and operations to include guidance information about engine problems encountered during the climb and cruise phases of flight. This amended guidance material will include information about aircraft handling, engine management, and decision-making during these phases of flight.

Read the final report: Collision with terrain - Piper PA-31P-350, VH-PGW, 6 km north-west of Bankstown Airport, New South Wales, on 15 June 2010

A new aviation bulletin featuring 11 investigation reports has just been released by the ATSB. The Aviation Short Investigation Bulletin Issue 14 covers short, office-based investigations conducted over the past six months. 

The bulletin covers incidents and accidents involving turboprop and piston aircraft, and helicopters. None of the accidents were fatal; however, some of the aircraft were seriously damaged.

Short investigations cover incidents and accidents where the associated factors are usually well-understood and do not require more detailed investigations. Nonetheless, each investigation has the potential to produce important Safety Messages for pilots, operators and others in the aviation industry. The investigations also help the ATSB identify statistics and trends in air safety.

The incidents covered in the report include:

• Propeller strike involving Fairchild SA227-DC, VH-WBQ (AO-2012-106)
• Depressurisation event involving a Metro 3, VH-SEF (AO-2012-127)
• Two aircraft proximity events at Ballarat airport (AO-2012-102)
• Inadvertent landing gear retraction involving Aero Commander, VH-YJS (AO-2012-110)
• Airspace related event between Cessna 172, VH-EPB and Piper Warrior, VH-BZE (AO-2012-111)
• Fuel starvation involving Piper Seneca, VH-BTW (AO-2012-112)
• Runway excursion involving Piper PA-28, VH-SFK (AO-2012-113)
• Engine failure involving Piper PA-32, VH-FAJ (AO-2012-125)
• Hard landing involving Cessna P206B, VH-EGG (AO-2012-135)
• In-flight fire involving Eurocopter AS-350BA, VH-HEB (AO-2012-084)
• Collision with terrain involving Kawasaki 369HS, VH-JWJ (AO-2012-104)

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 14