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 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

A rare engine malfunction on a Boeing 747-400 reminds operators to be alert to signs of wear and fatigue.

A Qantas Boeing 747-400 on a flight between Sydney and Singapore on 9 May 2011 experienced a malfunction in one of its engines that led the crew to shut it down. The aircraft continued safely to Singapore.

Operators of Rolls Royce RB211-524 engines have been alerted to the potential for wear and degradation of the IP turbine blade interlocking shrouds...

Indications from the engine included an increase in exhaust gas temperature and vibrations, which continued after the crew reduced the engine’s thrust. The ATSB found that the problem resulted from the failure and separation of a single intermediate-pressure (IP) turbine blade.

The blade had fractured following the initiation and growth of a fatigue crack from an origin area near the blade inner root platform. The manufacturer undertook detailed modelling and analysis. While it has not fully identified the root cause of the fracture, wear and loss of material from the turbine blade interlocking shrouds may have reduced the rigidity and damping effects of the shroud, contributing to the high-cycle cracking and failure.

The engine manufacturer issued a non-modification service bulletin in October 2011. The Bulletin required operators to perform a once-around-the-fleet inspection of IP turbine blades for missing shroud interlock material by June 2012. The aircraft operator advised that they had completed inspections across their fleet with no instances of excessive wear detected.

Operators of Rolls Royce RB211-524 engines have been alerted to the potential for wear and degradation of the IP turbine blade interlocking shrouds, with the possibility that this mechanism, if not detected and addressed, could lead to turbine blade cracking and loss. Service experience has shown that the probability of a failure of an IP turbine blade failure is very low and while it may cause malfunctions necessitating shutdown, the risks to flight are minor.

Read the final report: In-flight engine malfunction – Boeing 747-438, VH-OJH, 100 km south-east of Bali International Airport, Indonesia, on 9 May 2011

The ATSB’s Chief Commissioner, Martin Dolan, has just published his latest blog post. 

In the post, Martin talks about 'No-blame' investigations and why they are important to improve the system of safety.

Read Martin’s post and contribute to the discussion at www.atsb.gov.au/infocus

A new ATSB research report examines the effectiveness of safety management systems (SMS) and provides important insights for operators and organisations. 

SMS refer to organisations having a systematic approach to managing safety, including organisational structures, accountabilities, policies and procedures. They generally include common elements such as explicit management commitment to safety, appointment of key safety personnel, hazard identification and risk mitigation, safety investigations and audit, and safety performance monitoring. 

This research is especially timely because aviation, marine and rail industries have all recently incorporated safety management systems into regulations and operations as a required way of managing safety. Although Australia’s transport industries’ SMS approach is following world’s-best practice, there has been little empirical evidence presented as support for how the SMS approach actually influences safety. 

Dr Matthew Thomas undertook a comprehensive search of the literature that exists around SMS, examining existing studies and comparing their findings. The review found that safety management systems do appear to reduce accidents and improve safety in high-risk industries. At present, however, there have only been a small number of quality evaluations and it is unclear as to whether any individual elements of a SMS have a stronger influence on safety than other elements. At the same time, it is clear that management commitment and appropriate safety communications do affect attitudes to safety. Transport organisations that provide an appropriate investment and commitment to a safety management system should receive a positive return on safety. 

Read the research report: XR-2011-002, A Systematic Review of the Effectiveness of Safety Management Systems, contains detailed descriptions of its methods and findings.

Robinson R22 helicopter pilots are being urged to regularly check and maintain their aircraft’s drive system following a fatal accident in North-West Queensland.

• ATSB investigation identifies a drive belt failure in a fatal accident of a Robinson R22 helicopter.
• R22 pilots and operators need to regularly check drive system for misalignment and abnormal wear.
• Importance reaffirmed of pilot proficiency in autorations in case of a loss of main rotor drive.

While mustering near Julia Creek on 9 May 2011, a Robinson R22 helicopter was flying close to the ground when it lost drive to the rotor system. This resulted in a high rate of descent before the helicopter hit the ground. The pilot, the only occupant of the helicopter, died in the accident.

As a result of the drive failure and operating conditions at the time, the pilot needed to make an autorotative landing from a low altitude and at minimal speed.

The ATSB found that two v-belts that transfer torque from the engine to the rotor system had failed. The damage to the forward v-belt indicated that it had partially dislodged from the drive sheave, resulting in significant damage to the belt. At some point, the v-belt fragmented, compromising the redundancy of the belt-drive system. Once the rear v-belt failed, all drive to the rotors was lost.

As a result of the drive failure and operating conditions at the time, the pilot needed to make an autorotative landing from a low altitude and at minimal speed. Autorotation is a descent with power off—the helicopter’s rotor system continues to rotate at about normal RPM as a result of the air flowing upwards through the main rotor system. There was limited time for the pilot to recognise the condition, respond accordingly and for the autorotation to develop. This resulted in a high rate of descent at impact.

The accident reaffirms the important advice in ATSB safety advisory notice AO-2011-060-SAN-001. The notice highlights the need for R22 helicopter pilots and operators to pay careful attention to the installation, maintenance and inspection of drive belts and other components of the helicopter’s drive system.

The accident also highlights the importance of pilot proficiency in autorotations during emergency situations. When performing autorotations, there are a number of factors that must be considered in planning and execution to achieve a successful outcome. The ATSB Research and Analysis Report into Helicopter Accidents 1969–88 includes useful information on the risks associated with autorotations.  

Read the final report: Collision with terrain - Robinson R22 Beta II, VH-DSD, 85 km north-west of Julia Creek, Queensland, on 9 May 2011

The ATSB’s Chief Commissioner, Martin Dolan, has just published his latest blog post. 

In the post, Martin talks about the ATSB’s investigative focus on human error and how good safety systems need to detect and manage errors when they do occur. Martin also emphasises the importance of human factors in the ATSB’s role to improve transport safety. 

Read Martin’s post and contribute to the discussion at www.atsb.gov.au/infocus

An incident at Mackay Airport has highlighted the potential distraction presented by portable communication devices, especially in the dynamic airside environment.

On 29 June 2012, a Piper PA-31 Navajo aircraft, took off from runway 05 at Mackay Airport. At that time, an Airport Safety Officer (ASO) was conducting an airfield runway and lighting inspection in an airfield safety vehicle and moving in a north-westerly direction along runway 32. Despite an earlier air traffic control instruction to hold short of runway 05, the ASO was distracted by a telephone call and continued along runway 32, crossing runway 05. The Piper PA-31 passed over the airfield safety vehicle by an estimated vertical distance of 30 feet.

The ATSB reminds airport workers to always remain focussed during airside operations.

In 2012, Airservices Australia published the third edition of Third edition An Airside Driver's Guide to Runway Safety. This publication identified a range of safety measures intended to help reduce the likelihood of runway incursions, including information about situation awareness and communications. This publication also highlighted the importance of scanning runways before entering or crossing a runway.

A Department of Infrastructure and Transport road safety grant report titled In-car distractions and their impact on driving activities(Opens in a new tab/window) recognised that distraction from a mobile telephone may divert a driver’s mental and perceptual attention from the task of driving, and may increase response times to events.

The investigation report AO-2012-090 provides important advice about airside operations.

You can find this and other investigations in the ATSB’s Aviation Short Investigation Bulletin issue 13. The bulletin highlights valuable safety lessons for pilots, operators and safety managers.

Virgin Australia Airlines is reviewing their program to replace engine fuel feed crossfeed valves after a fuel imbalance on a flight from Gold Coast to Melbourne led to a declaration of a PAN and a diversion to Brisbane.

During climb, the crew observed that both engines were being supplied only from the right fuel tank, resulting in a fuel quantity difference between the left and right fuel tanks. The crew conducted the fuel leak engine checklist which confirmed that no engine fuel leak existed. With centre tank fuel available, the crew selected the centre tank pumps on, which resulted in the fuel imbalance stabilising.

Since the crew could not confirm fuel from the left tank could be used once the centre tank pumps were selected off, or that no fuel leak existed, they diverted to Brisbane. The aircraft landed without further incident.

An overhaul organisation inspected the engine fuel feed crossfeed valve and identified wear to the sealing materials and Teflon within the valve body as consistent with the existence of a leak within the valve. However, the overhaul organisation was unable to confirm whether the sealing material degradation would explain a high volume fuel leakage rate. 

...the crew selected the centre tank pumps on, which resulted in the fuel imbalance stabilising.

Virgin Australia Airlines had previously established an inspection program for the crossfeed valves in accordance with Boeing recommendations. The operator also has a program in place to replace existing crossfeed valves with a modified version at scheduled maintenance servicing.  This program is currently under review for acceleration.

You can find this and other investigations in the ATSB’s Aviation Short Investigation Bulletin issue 13. The bulletin highlights valuable safety lessons for pilots, operators and safety managers.

Read the final report: Fuel imbalance - Boeing 737, VH-VOL, 28 km south-west of Gold Coast Airport, Queensland, on 15 April 2012, which includes important advice.