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.

The ATSB investigation into an aircraft’s collision with terrain in Queensland has highlighted the vital importance of avoiding fuel contamination, and the value of using all safety equipment, including shoulder harnesses, in case an accident does occur.

On 19 June 2012, the Cessna 182P departed Mayvale Station, about 53 km from Cunnamulla, Queensland to conduct an aerial inspection of the property. The pilot, who was the only person on board, would later recall that, shortly after becoming airborne, at about 80 to 100 ft, the aircraft lost airspeed. Then, while conducting a forced landing, the aircraft clipped a tree. The next thing he could recall was being on the ground, out of the aircraft and unable to stand. The aircraft had collided with the ground and come to rest inverted. 

Although the aircraft was fitted with a single shoulder strap harness, the pilot had only fastened the seat belt. In order to afford the best possible protection against injury in the event of an accident, aircraft occupants should fasten both the seat belt and shoulder harness, where provided, particularly for take-off and landing.

A search was mobilised when the pilot failed to return and could not be reached by radio. Three hours after the accident, the seriously injured pilot was found. Although the aircraft was fitted with an Emergency Locator Transmitter (ELT), it had not activated, and a personal ELT carried by the pilot in the aircraft was inaccessible. 

The day before the accident flight, the pilot refuelled the aircraft from drum stock kept as an emergency fuel supply. The pilot did not test the drum fuel for water or contamination. Following the accident, a considerable amount of water was found in a number of fuel samples taken from the aircraft, and in a sample taken from the drum. 

Checking fuel for water and other contaminants is something pilots can never be too careful about. The following publications provide further information relating to refuelling and fuel checks: 

• ATSB Avoidable Accidents No. 3 – Managing partial power loss after take-off in single-engine aircraft 
• Civil Aviation Order 20.9 titled Air service operations – precautions in refuelling, engine and ground radar operations(Opens in a new tab/window)
• Safety on the ground, provides advice on refuelling from a drum, and on the correct way to store a fuel drum 
• The Cessna Pilot Safety and Warning Supplements (1998) 

Pilots are encouraged to leave a flight note with a responsible person, and carry their personal ELT on them, so that it is readily available when most needed.

Read the final report: Collision with terrain - Cessna Aircraft Company 182P, VH-WTS, 53 km east-north-east of Cunnamulla, Queensland, on 19 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.

Three incidents at Gladstone Airport have important messages for regional aviators. The incidents, captured on CCTV footage, show three high-capacity passenger aircraft taking off at night without activating the runway lighting.

Gladstone is a non-towered, uncontrolled airport operating on a common traffic advisory frequency. The runway lighting was controlled by a pilot active lighting system that was combined with an aerodrome frequency response unity. Once activated, the lighting remains on for 30 minutes from the time of activation or reactivation. In two cases investigated, the lighting deactivated between boarding and departure. In the other the lighting was not activated at all.  

All flight crew interviewed advised that, during the taxi and take-off roll, they did not notice anything unusual or problematic with the airport lighting or environmental conditions at the airport. In addition, they reported that they had no difficulties maintaining directional control during the take-off. Until the ATSB contacted them, the crews had not been aware that the lights had de-activated in between boarding the aircraft and the aircraft taking off.

These incidents highlight the potential hazards associated with change blindness, inattention blindness and expectation bias.

Change blindness occurs when a person does not notice that something is different about the visual environment relative to before the Potential Hazard change. Research has shown that in some cases, quite dramatic changes are not detected, particularly if changes occur when the observer is not looking at the relevant part of the visual environment at the time. In this instance the crews did not notice the difference between the airport lighting when they were boarding versus when they taxied out for departure.

Inattention blindness occurs when a person does not notice an object that is visible, but unexpected, because their attention is engaged on another task. In this instance the absence of lighting was noticeable, if looked for, and the crews probably had an assumption or expectation that the lighting was on.

In simple terms, expectation bias is ‘seeing’ what you expect to see even when it is not there—in this case, runway lighting being on.

Read the final report: Take-offs without runway lighting - VH-FVL (ATR-72), VH-FVU (ATR-72), VH-QOK (DHC-8)

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.

A new aviation bulletin featuring ten investigation reports has just been released by the ATSB. The Aviation Short Investigation Bulletin issue 12 covers short, desk-based investigations that took place between April and July this year.  The bulletin covers incidents and accidents involving jet, turboprop and piston aircraft, and helicopters. None of the accidents were fatal; however, one pilot sustained serious injuries and some of the aircraft were seriously damaged or destroyed.

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:

• Fumes event – Boeing 7373, VH-VBL (AO-2012-060)
• Take-offs without runway lighting (AO-2012-069)
• Partial power loss – Gippsland Aeronautics GA8, VH-WOV (AO-2012-062)
• Airspace related event – Amateur Built Van’s RV-8, VH-YGY (AO-2012-067)
• Fuel contamination – Cessna 182P, VH-WTS (AO-2012-083)
• Total power loss – Gippsland Aeronautics GA-8 Airvan, VH-FCK (AO-2012-092)
• Collision with terrain – Guimbal Cabri G2, VH-ZZT (AO-2012-055)
• Collision with terrain – Robinson R44 Raven 1, VH-HOU (AO-2012-078)
• Wirestrike – Robinson R44, VH-HIE (AO-2012-079)
• Collision with terrain – Schweizer 269C-1, VH-LTO (AO-2012-082)

Read the ATSB's Aviation Short Investigation Bulletin - Issue 12