The partial incapacitation of a pilot has shown how important it is for pilots to assess their own wellbeing and ability to fly, just as they do for their aircraft. 

In this case, the pilot and a flight nurse were flying from Sydney to Port Macquarie in a Raytheon B200 aircraft to pick up a patient.

The aircraft landed at Sydney and after shutdown the pilot became physically ill.

After departing Sydney, the pilot began to feel unwell, experiencing abdominal pain and nausea. After donning his crew oxygen mask, the pilot’s health improved and commenced a return to Sydney. During the descent, the pilot removed his oxygen mask and, soon after, he began to feel unwell again.

The aircraft landed at Sydney and after shutdown the pilot became physically ill. The pilot recovered from the illness about one week later. It was found that he most likely suffered viral gastroenteritis.

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.

The following resources provide more information about pilot incapacitation and help you to assess if you are fit to fly:

• Pilot Incapacitation: Analysis of Medical Conditions Affecting Pilots Involved in Accidents and Incident – 1 January 1975 to 31 March 2006
• Federal Aviation Administration Risk Management Handbook(Opens in a new tab/window)
• I.M S.A.F.E. Checklist(Opens in a new tab/window)

The Investigation report AO-2012-100 provides important advice on crew incapacitation.

A new aviation bulletin featuring 10 investigation reports has just been released by the ATSB. The Aviation Short Investigation Bulletin issue 13 covers short, office-based investigations.

The bulletin covers incidents and accidents involving jet, turboprop and piston aircraft, helicopters, and other vehicles. None of the accidents were fatal; however, one pilot sustained serious injuries and 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:

• Fuel imbalance – Boeing 737, VH-VOL (AO-2012-053)
• Breakdown of separation – Boeing 737-438 and Fairchild SA227 (AO-2012-087)
• Partial pilot incapacitation – Raytheon B200, VH-MSH (AO-2012-100)
• Breakdown of separation – Beech 200, VH-FDD and Beech 350, DINGO 008 (AO-2012-101)
• Aircraft proximity event – Piper PA-34, VH-PWQ and Cessna R182, VH-JYG (AO-2012-071)
• Aircraft proximity event – two Cessna 172S, VH-EWE and VH-EOP (AO-2012-099)
• Hard landing – Cessna 172S, VH-EOP (AO-2012-114)
• Collision with terrain – Robinson R22, VH-STK (AO-2012-091)
• Runway incursion – Perth airport safety vehicle (AO-2012-086)
• Runway incursion – Mackay airport safety vehicle (AO-2012-090)

Read the ATSB's Aviation Short Investigation Bulletin - Issue 13 (AB-2012-141)

Priorities for further improving the safety of Australia’s aviation, maritime and rail industries have been featured in the ATSB’s new online initiative, Safety Watch, released today in conjunction with the Chief Commissioner’s blog, In Focus.

ATSB Chief Commissioner, Mr Martin Dolan, said that while the ATSB has not seen any overall increase in risk to Australia’s transport safety, the transport community should consider opportunities to make safe transport systems even safer.

“The priority areas are based on accident and incident trends the ATSB has observed from investigation findings and occurrence reports,” Mr Dolan said.

“For aviation, there are opportunities for improvement in operations ranging from general aviation to high capacity airlines. Some of the risk areas involve wirestrikes, low-level flying, fuel management, handling of approach to land, and data input errors.

“Marine work practices continue to be a priority area, particularly in or around ships and loading areas. In addition, we’ve identified concerns with the challenging environment of coastal pilotage.

“For rail, the ATSB sees opportunities to improve the safety of workers on railway tracks following several accidents that occurred when track maintenance work was being undertaken.

“The ATSB has launched Safety Watch to help improve the transport community’s awareness of these safety priorities,” Mr Dolan said. “It provides a specific briefing for each of the identified issues, describing what the priorities are, and what can be done to manage the risk.”

Safety Watch is available at www.atsb.gov.au/SafetyWatch

InFocus is available at www.atsb.gov.au/InFocus

An accident in the Northern Territory that left two pilots injured has demonstrated the major hazard that dust devils can pose to light aircraft during landing. It also shows the virtues of conducting an early go-around, should an approach become unstable. 

On 18 April 2012, at about 1200, a Cessna 210 was attempting to land at the Nyirripi aircraft landing area in the Northern Territory. Although there were dust devils forecast, the supervisory pilot reported that there were none observed at Nyirripi. 

The supervisory pilot reported that, during the landing flare, the aircraft had not been slowed sufficiently. As a result, the aircraft ballooned twice. The supervisory pilot took control of the aircraft with the intent of recovering to a normal landing. A gust of wind, however, caused the aircraft to yaw significantly to the left. The supervisory pilot applied full power to go-around but the aircraft did not climb. He then rolled the aircraft into a thirty-degree right bank to remain over clear ground, closer to the runway. 

Realising that the aircraft was going to impact the ground, the supervisory pilot rolled the wings level. The aircraft impacted fairly hard and skidded about 100 m before coming to rest north of the runway and about 600 m from the threshold. The supervisory pilot was seriously injured and the pilot in command under supervision sustained minor injuries. 

The aircraft operator has since issued guidance notes to all flight crew regarding windshear recognition and recovery, as well as a reminder of information in the procedures manual. 

Read the final report: Collision with terrain - Cessna 210, VH-TWP, Nyirripi (ALA), Northern Territory, on 18 April 2012, which includes important advice, and also provides links to other useful sources of information on the subject. 

You can find this and other investigations in the ATSB’s Aviation Short Investigation Bulletin issue 11. The bulletin highlights valuable safety lessons for pilots, operators and safety managers.

An incident at Melbourne Airport in which an aircraft on approach descended 500 ft lower than cleared has demonstrated the importance of a resilient safety management system. It also shows the safety benefits of clear operator procedures in the management and use of safety-critical navigation data.

The event took place on 7 June 2011, as an Airbus A320, operated by Tiger Airways, was on an approach to runway 27 at Melbourne Airport, Victoria. Air traffic control (ATC) had cleared the aircraft to descend to 2,500 ft. Shortly after, ATC identified that the aircraft had descended to 2,000 ft, below the limiting altitude for that segment of the approach. ATC notified the flight crew of the deviation. The crew re-established the aircraft at 2,500 ft, then continued the approach and landed.  

The ATSB found that the flight crew had based the descent profile on information displayed on the aircraft’s Multipurpose Control and Display Unit (MCDU). The MCDU drew on information stored in the aircraft’s flight management guidance system (FMGS). The FMGS information included data provided through a third party that had a missing altitude limitation. That limitation was, however, included in the paper charts also used by the crew but the data anomaly was not identified by the crew during their preparation for the approach. 

The ATSB also found there was an increased risk of inadvertent non-compliance with published instrument approach procedures because of the inconsistent application of the operator’s safety management system to the identification and management of database anomalies. In addition, different assumptions by the data suppliers and the operator compromised the quality assurance of the navigational data. 

The action by ATC to alert the flight crew triggered their recovery to the required flight profile.

In response to this occurrence, Tiger Airways implemented an auditable process for identifying and managing navigational database anomalies in its aircraft fleet.

Read the final report: Operational non-compliance - Airbus A320, VH-VNG, 17 km east-north-east of Melbourne Airport, Victoria, on 7 June 2011

The ATSB website now offers a text-to-speech service called ReadSpeaker—an application that lets you listen to text on the ATSB website.

Wherever you see this icon. 

 ReadSpeaker will read the text out loud for you.

You can also listen to PDFs through ReadSpeaker when you click the ‘Listen to this PDF’ link, located near the Download PDF icon.

ReadSpeaker means you can listen to our website content from any device connected to the Internet. It will help people who have trouble reading text online better understand the information on the website. Listening to audio is another way to explore our website, particularly if you spend long periods of time on your computer or mobile phone.

You don’t have to download anything to use ReadSpeaker. When you click the ‘Listen’ button a control panel will appear and ReadSpeaker will automatically start reading the web page out loud.

In the control panel you can:

• adjust the volume
• pause the reading
• stop and restart the reading
• choose ’No sound? if you want to download an MP3 audio file
• choose ‘Settings’ if you want to customise the ReadSpeaker service.

If you only want to listen to a few paragraphs, select the text that you want to listen to and then press the pop-up listen button  

which appears next to the mouse pointer after you have made your selection.

 Any questions or feedback? Email the ATSB at atsbinfo@atsb.gov.au

As a result of the ATSB investigation and in order to reduce the level of risk associated with emergency training, a helicopter operator is investigating amendments to their company operations manual. 

One amendment being investigated by the operator is the requirement for at least 10 kts of wind in the runway direction for the performance of low-level practice operations. This is an important safety action, as ATSB research indicates that for helicopters the greatest risk of an accident occurs during the performance of practice autorotations.

The accident occurred on 18 June, 2012, when an instructor and student were conducting emergency procedures training in the circuit at Redcliffe aerodrome in Queensland. They were flying in a Schweizer 269C-1 helicopter and, as part of a bi-annual flight review, were carrying out low-level autorotations to simulate an engine failure on approach. (Autorotation occurs during descent with the power off. The air flowing in reverse direction upwards through the lifting rotor(s) causes it to continue to rotate at approximately cruise RPM.)

When the helicopter was at about 250 ft above ground level and 55 kts airspeed, the instructor called for a practice engine failure. The student closed the throttle and lowered the collective to enter autorotation. Power was restored shortly after, by opening the throttle in anticipation of a power termination. The student flared the helicopter, however the helicopter did not decelerate as expected. The instructor increased the flare in an attempt to arrest the rate of descent and decrease the groundspeed. 

The tail rotor struck the ground and the helicopter pitched forward. The crew closed the throttle in an attempt to recover from an uncommanded right yaw, however the helicopter impacted the ground before the rotation could be arrested and the helicopter rolled over. The helicopter was seriously damaged. Both instructor and student reported soft tissue injuries and some minor cuts and bruises.

The reason for the accident could not be conclusively established, however it was considered likely that the helicopter encountered low level wind shear during the flare resulting in a tail rotor strike and subsequent loss of control. 

When performing autorotations, there are a number of factors that must be considered in planning and execution to achieve a successful outcome. The investigation report AO-2012-082 includes important advice, and also provides links to other useful sources of information on the subject.

You can find this and other investigations in the ATSB’s Aviation Short Investigation Bulletin issue 12. The bulletin highlights valuable safety lessons for pilots, operators and safety managers.

The ATSB’s investigation into a wirestrike accident highlights the importance of a proper reconnaissance when flying in a wire environment and remaining focused only on operational tasks.

On 12 June 2012, a Robinson Helicopter Company R44 Raven 1 helicopter departed Moorabbin Airport, Victoria with one person on board to conduct a private flight to a property at Moolort, Victoria.

During the flight, the pilot decided to check on the progress of a bore under construction about 2 km west of his intended destination. The pilot landed at the bore site and, after a short time on the ground, decided to depart in the same direction as his approach.

As the helicopter transitioned from the hover to forward flight, the pilot saw a single strand powerline directly ahead. There was no time to avoid the wire and the helicopter struck the wire on the middle of the main rotor mast. The helicopter swung upwards on the wire and the pilot remembered seeing the sky before the wire broke, releasing the helicopter.

The pilot had limited control and was able to change the attitude to remain relatively straight and level until the helicopter landed heavily. The pilot was not injured, however the helicopter sustained serious damage.

The pilot reported that he had been focused on avoiding the main powerline and had not seen the second powerline during his scans of the area on arrival or prior to departure.

The accident highlights the importance of a proper reconnaissance when flying in a wire environment and remaining focused only on operational tasks. The pilot's reaction to the wirestrike, which was to continue to fly the aircraft to the ground, assisted him to land without injury.

ATSB research has found that wirestrikes are the third most prevalent cause of fatal accidents in private flying operations. Research into aerial agriculture accidents found that wirestrikes occurred even when pilots knew the location of wires. Although this accident was not related to agricultural operations, the research found that focusing only on operational tasks while flying was an important habit to develop.

Read the final report: Wirestrike - Robinson R44, VH-HIE, 21 km east of Maryborough Airport, Victoria, on 12 June 2012

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

The ATSB has investigated several occurrences of reported partial power loss situations where carburettor icing was suspected.

On 10 June 2012, a Robinson Helicopter Company R44 Raven 1 was seriously damaged following a reported loss of power and collision with terrain near Maryvale in the Northern Territory. 

The helicopter was providing support and aerial filming of a competitor participating in the annual Finke Desert race with a pilot and three passengers on board. 

The helicopter impacted the ground in a level attitude collapsing the skids on impact. One passenger was seriously injured in the accident.

The ATSB could not determine a definitive reason for the reported loss of engine power, however, a review of the carburettor icing probability chart revealed that the temperature/dew point spread, put the flight in the ‘serious icing – descent power’ operating realm.

When an aircraft is fitted with a carburettor air temperature gauge, carburettor heat is applied to a level to maintain the temperature outside the caution range. The carburettor heat assist system fitted to the Robinson R44 Raven 1 is designed to automatically apply a level of heat corresponding to the amount of power being applied. It does not directly sense carburettor air temperature and further adjustments may be required to be made by the pilot to maintain the temperature outside the caution range. 

Robinson Helicopter Company has previously issued advice about the use of the carburettor heat assistance system, warning that if used it will reduce carburettor heat on lift off and may require adjustment in flight.

The ATSB encourages operators and pilots to learn more about the dangers and methods of preventing carburettor icing.

Read the final report: Collision with terrain - Robinson R44, VH-HOU, 93 km south of Alice Springs Airport, Northern Territory, on 10 June 2012

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

One of the greatest concerns for pilots operating single-engine aircraft is the prospect of a total power loss at night. Should such an event occur, it is crucial that pilots are mentally prepared to act immediately. 

 On 6 July 2012, a Gippsland Aeronautics GA-8 Airvan aircraft departed Tennant Creek on a night training flight to Alice Springs in the Northern Territory. 

After monitoring a gradual drop in the oil pressure, the crew began planning for a diversion to the Ti Tree aeroplane landing area (ALA). The instructor had flown into the ALA the previous week and successfully used the pilot activated lighting (PAL) system.

At about 2000, the engine oil pressure light illuminated, necessitating an immediate landing. The crew diverted to the Ti Tree ALA and attempted to activate the runway PAL system, without success. 

Shortly after, near the township of Ti Tree, the engine began to run rough and subsequently stopped. 

When the instructor noticed a vehicle travelling on a road to the north of the town, the crew elected to abandon the landing at the unlit ALA and, following the vehicle’s lights, carried out a successful landing onto the Stuart Highway.

The crew were faced with an engine failure at night in a remote location, which was further exacerbated by the unsuccessful activation of the PAL runway lighting system at the Ti Tree ALA. 

By quickly changing their plan, the crew made a successful landing on a road, without injury or damage to the aircraft. This incident demonstrates how a quick response to an adverse situation can result in a positive outcome.

Read the final report: Total power loss - Gippsland Aeronautics GA-8, VH-FCK, Ti Tree, Northern Territory, on 6 July 2012

ATSB’s Aviation Short Investigation Bulletin highlights valuable safety lessons for pilots, operators and safety managers.