Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On 18 February 2018, an Airbus A320-232 departed Melbourne, Victoria (Vic.) on a scheduled passenger flight to Sydney, New South Wales (NSW). At about 0915 Eastern Daylight-saving Time (EDT), cabin crew were alerted to a fire in the cabin.
The cabin crew traced the source of the fire to three smartphone devices located in a passenger bag at row five. The crew subsequently discharged a fire extinguisher and followed the operator’s procedure for the management of a lithium battery fire. The fire was successfully extinguished, and the devices isolated in a container until the end of the flight.
Safety message
Personal electronic devices (PEDs) such as smartphones contain lithium batteries, which are classed as dangerous goods. The incidence of passenger smartphones resulting in fire on board aircraft has increased. The Civil Aviation Safety Authority (CASA) has published advice on the ‘Least wanted dangerous goods’ carried by passengers. Lost or damaged smartphones were identified as the number one hazardous item on passenger aircraft in 2017. Previous Australian Transport Safety Bureau (ATSB) investigations AO-2016-051 and AO-2016-066 provide further examples of incidents of passenger smartphones causing in-flight fires and smoke events.
This incident highlights the need for passengers to become familiar with the hazards associated with the carriage of personal electronic devices, in particular, the potential for fire if a device is damaged or overheated.
Fire on board aircraft is potentially catastrophic if not managed quickly and appropriately. It is important for operators to ensure crew receive training and are periodically tested in the management of lithium battery fires on board aircraft.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On 18 January 2018, an Aero Commander 500-U departed Cobar, New South Wales (NSW), for Charleville, Queensland (Qld). Another aircraft, Mooney M20J, was also airborne at the same time, flying from Broken Hill, NSW, to Archerfield, Qld.
During cruise at 8,500 ft, the pilot of the 500-U observed traffic on their electronic flight bag (EFB) application in their 10 o’clock position at 10 NM. The EFB application indicated the traffic was within 200 ft of the 500-U’s altitude. The pilot of the 500-U reported that the application displayed the relative positions of the two aircraft remained constant and the distance between them was reducing.
The pilot of the 500-U initiated contact with the crew of the M20J, resulting in the M20J descending to 7,500 ft. Two minutes later, the 500-U pilot observed the M20J passing directly underneath, crossing their track at almost 90 degrees.
Airspace
The aircraft passed each other in Class G airspace. Class G airspace is non-controlled airspace in which IFR[1] and VFR[2] aircraft are permitted to operate without a clearance. There is no air traffic control separation service in Class G airspace.
Weather
The pilot of the 500-U reported that a grey haze prevented sighting the M20J until it passed directly underneath.
Safety message
This occurrence highlights the importance of following the altitude requirements for VFR flight (see Figure 1) in uncontrolled airspace. This is especially significant when considering the limitations discussed in the ATSB research report Limitations of the See-and-Avoid Principle.
Figure 1: Table of VFR cruising levels
Source: Aeronautical Information Publication Australia
It also highlights the importance of monitoring area frequency for potential traffic and that electronic aids can be used as a supplementary tool that may enhance maintaining situational awareness.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On 7 January 2018, at about 1327 Eastern Daylight-saving Time (EDT), a Fairchild Industries Inc. SA227-DC was conducting training exercises in the circuit area at Ballina, New South Wales, with two crew on board. While on the downwind leg of the circuit, the crew noticed the right engine fire warning light had illuminated on the warning panel. The warning light went out as the crew were about to commence the memory items required for an engine fire warning, and the approach and landing were completed normally.
After parking and shutting the aircraft down, the crew identified smoke stains on the cowls of the right engine. Further inspection revealed evidence of a fire on the upper rear section of the engine. The aircraft was subsequently grounded pending a maintenance inspection.
Maintenance engineers identified a fuel leak from the manifold had ignited resulting in damage to the fuel lines and associated fittings and controls in the immediate vicinity (Figure 1). All damaged parts were replaced and tested prior to the aircraft being returned to service.
Figure 1: Pictures of fire damaged components within the right engine bay
Source: Operator
Safety action
As a result of this occurrence, the operator has advised the ATSB that they have taken the following safety action.
Inspections have been completed on all aircraft in the fleet with no other potential fuel system faults identified.
Safety message
This incident highlights the importance of flight crews maintaining awareness of all system states and being prepared to act at the first sign of trouble. A fire during flight has the potential to rapidly propagate unless it is quickly identified and managed, and the aircraft landed at the earliest opportunity.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On 22 February 2018, a Piper PA-28R departed from a local aerodrome to travel to Sunshine Coast Airport, Queensland (Qld). The weather at the time included rain showers, low cloud and reduced visibility. Approaching the airport, the pilot progressively descended the aircraft to remain clear of cloud.
Air traffic control (ATC) advised the pilot that further adverse weather was approaching the airport and provided options to divert to a suitable landing area. The pilot elected to continue, arriving into the circuit at low level in deteriorating weather conditions.
ATC issued a ‘check gear down’ warning to the aircraft shortly before being unable to maintain visual contact with the aircraft in the circuit.[1] Air traffic controllers further issued a ‘Safety Alert, Terrain’[2] call as the aircraft manoeuvred to the north of the airport in the proximity of Mt Coolum (682ft). Air traffic control regained visual contact with the aircraft on short final.
The pilot reported that approaching the airport in the reduced visibility, he relied upon vertical visual contact with the ground to maintain his situational awareness when the horizontal visibility deteriorated. The pilot also stated that he was familiar with the local area and carried two Garmin GPS[3] and two iPads with planning and navigation software.
Figure 1: Sunshine Coast Airport proximity to Mt Coolum, Qld
Source: Google Earth Pro Image 31 October 2017 with ATSB annotations
Table 1: VMC criteria for aeroplanes below 3,000ft above mean sea level
Class of Airspace
Flight Visibility
Vertical and Horizontal distance from cloud
Conditions
Class G (Uncontrolled) or within 1,000 ft of ground
5,000M
Clear of cloud and in sight of ground or water
Radio must be carried and used on the appropriate frequency
Class D (Controlled)
5,000M
600M horizontal 1,000FT vertically above cloud
Or 500FT vertically below cloud
ATC may permit operations in weather conditions that do not meet these criteria
(Special VFR).
Source: Aeronautical Information Publication (AIP) Australia: ENR 1.2-4 10 November 2016
Safety message
Pilots are encouraged to make conservative decisions when considering how forecast weather may affect their flight. If poor weather is encountered en-route, timely and conservative decision making may be critical to a safe outcome.
VFR[4] pilots are also encouraged to familiarise themselves with the definition of VMC criteria, and carefully consider available options where forecast or actual conditions are such that continued flight in VMC cannot be assured.
The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry.
Avoiding deteriorating weather or IMC[5] requires thorough pre-flight planning, having alternate plans in case of an unexpected deterioration in the weather, and making timely decisions to turn back or divert.
Pressing on into IMC conditions with no instrument rating carries a significant risk of severe spatial disorientation due to powerful and misleading orientation sensations in the absence of visual cues. Disorientation can affect any pilot, no matter what their level of experience.
VFR pilots are encouraged to use a ‘personal minimums’ checklist to help control and manage flight risks through identifying risk factors that include marginal weather conditions.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On 7 January 2018, the pilot of the Cessna 152 departed Jandakot, Western Australia (WA) to conduct aerobatics. The pilot was the only occupant.
At approximately 1412 Western Standard Time (WST) following an aerobatic-loop, the pilot applied power and the engine failed to accelerate. The pilot completed the emergency checklist, but the engine would not accelerate beyond 1900 RPM. The pilot searched for a suitable landing area, finding Lake Walyungup to be suitable. The pilot then made a PAN-PAN and later a MAYDAY radio transmission. The pilot conducted a successful forced landing on the dry surface of the lake.
The aircraft did not sustain any damage as a result of the landing. The post-flight inspection revealed the carburettor to be the cause of the failure. Metal contamination was detected in the carburettor which was likely disturbed during the aerobatics resulting in the partial engine failure. The source of the contaminants could not be identified.
Safety message
Simulated total loss of power and a subsequent practice forced landing is at the core of a pilot’s emergency training. However, data shows that for light single-engine aircraft a partial power loss is three times more likely to occur than a complete engine failure.
Following the partial engine failure, the pilot in this occurrence had to make important decisions in a short space of time, where to land and how to manage the remaining altitude. The ATSB’s publication and YouTube video ‘Managing partial power loss after take-off in single-engine aircraft’ is available on the ATSB website.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On 4 January 2018, at about 0900 Central Daylight-saving Time (CDT), a Robinson R22 helicopter departed from a private property in Katherine, Northern Territory. The pilot, who was the sole occupant, was conducting a private flight to obtain GPS coordinates of structures on a property 38 km south-west of Tindal, NT.
The pilot landed the helicopter alongside a fence line in long grass. The pilot remained in the helicopter, with the engine running and obtained coordinates as required. The pilot then manoeuvred the helicopter into a low hover and with the breeze coming from the north-east, commenced to move out of the hover and felt the helicopter move to translational lift.[1] The pilot lifted the power to maximum take-off while easing the cyclic[2] forward to take advantage of the headwind.
As the helicopter straightened, about 3 ft above ground level (AGL), it dipped suddenly, pivoting on the front left-hand skid. The pilot attempted to pull the cyclic back but the helicopter rolled to the left and the main rotor blades contacted the ground at full power, almost severing them at the blade roots. The main rotor blades cut the tail boom into three pieces, lodging the tail rotor and assembly into the ground about 5 m in front of the fuselage. The fuselage came to rest on the left side.
Although hanging from his seatbelt, the pilot was able to shut off the master; however, was unable to reach the fuel shut off valve. The pilot’s seat base dislodged and fell off once the pilot released himself from the seatbelt.
Post-accident observation
The pilot observed two old barbed wires leading from the fence line at a 45-degree angle One wire appeared to have broken with impact and the other wire was entangled around the front left-hand skid.
The wires were half buried in the ground and below the grass top level, making them invisible.
Figure 1: Accident site showing fence wire
Source: Operator
Safety action
As a result of this occurrence, the pilot has advised the ATSB that they are taking the following safety actions:
avoid landing in grass any higher than skid tube height
conduct a thorough visual inspection when lifting off around fences.
Safety message
This incident provides a reminder to pilots to conduct a thorough visual inspection to confirm wire locations and other hazards.
This accident highlights the value of restraints and safety helmets for pilots to prevent more serious injury.
ATSB report AO-2014-058 provides an account of a serious head injury to an R22 pilot who was not wearing a helmet. In a later ATSB report, AO-2015-134, the operator commented that the pilot of an R22 accident would have sustained more serious head injuries if he was not wearing a helmet.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On 7 January 2018, a Robinson R66 helicopter departed the north coast of Kangaroo Island on a private flight to Aldinga Airport, South Australia. Upon reaching the mainland, the pilot observed what appeared to be sea fog from the north; however, the pilot then realised it was smoke from a grass fire at Carrickalinga, SA. The pilot advised he was listening on the area frequency and did not hear any notifications regarding a grass fire in the area so continued towards Aldinga at 2,000 ft.
About 10 NM SW of Aldinga Airport as shown in Figure 1, the crew of the Aerospatiale AS350 was conducting and directing fire control services at Carrickalinga and providing periodic transmissions on the Aldinga common traffic advisory frequency (CTAF). The transmissions were for inbound and outbound aircraft in order for them to keep clear of the aircraft conducting fire control below 2,500 ft.
At approximately 1400 Central Daylight-saving Time (CDT), the crew of the AS350 observed the Robinson R66 pass below on an opposite track. The crew of the AS350 turned left and climbed to increase separation. Information from both pilots estimated the distances between the aircraft to be of different clearance heights. The pilot of the R66 advised they were visual with the AS350 at all times. As the R66 passed Carrickalinga, the crew changed to the Aldinga CTAF to provide their 10 NM inbound call, and were notified by the crew of the AS350 of the fire exclusion zone.
Figure 1: Distance from Carrickalinga, SA to Aldinga Airport, SA
Source: Google Earth, annotated by ATSB.
Airspace
Class G airspace
Class G airspace is non-controlled airspace. IFR and VFR traffic are permitted without a clearance and there is no separation service provided by air traffic control. Aldinga Airport is a non-controlled aerodrome with a discrete CTAF, which is a different frequency from the surrounding Class G airspace area frequency.
Safety action
As a result of this occurrence, the pilot of the AS350 has advised the ATSB that the incident has been shared among their company to highlight the importance of area frequency scans even when monitoring the local CTAF.
Safety message
This incident highlights the importance of monitoring the area frequency and local CTAF when operating nearby the 10 NM radius to successful identify any potential traffic conflict. As bushfire season has commenced in Australia for 2018 this incident has put attention to when bushfires are observed to try and avoid the area if possible or to ask ATC on the area frequency if there is an exclusion zone in place for fire control operations. Further information is available from ATSB research report: Limitations of the See-and-Avoid Principle.
The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of the safety concerns relates to safety around non-controlled aerodromes.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
The Australian Transport Safety Bureau (ATSB) urges operators and owners of piston-engine aircraft to know about the presence of carbon monoxide (CO) by using an active warning detector.
CO is a colourless and odourless gas, and its presence may not be detected until the physical symptoms and cognitive effects present themselves. When inhaled, CO preferentially binds to haemoglobin, the oxygen carrying molecule in red blood cells. This creates carboxyhaemoglobin (COHb) compounds and prevents oxygen from binding to the molecule and being transported, resulting in oxygen starvation.
Symptoms can include breathlessness, confusion, disorientation and incapacitation.
Disposable chemical spot detectors, as commonly used in general aviation, may be effective in warning pilots of the presence of CO, but they have known limitations. Spot detectors are passive devices that relies on the pilot regularly monitoring it for discolouration. In addition, identifying a positive indication is also dependent on the detector being easily visible and accessible. Plus, these detectors do have a limited shelf-life when removed from their original packaging, which may be further affected by factors such as exposure to harsh direct sunlight, cleaning chemicals, and halogens.
The ATSB highlighted its concerns regarding exposure to CO when it issued two Safety Advisory Notices arising from its investigation into the collision with water of a DHC-2 Beaver aircraft in Jerusalem Bay, north of Sydney, in which the pilot and five passengers were fatally injured.
Toxicological testing of blood samples found the pilot and two passengers had elevated levels of CO. The levels detected were likely to have adversely affected the pilot’s ability to control the aircraft during the flight. The aircraft was fitted with a disposable chemical CO spot detector.
From the investigation, the ATSB published a Safety Advisory Notice, to piston-engine aircraft owners and pilots, reiterated the importance of the use of an active CO detector in the cabin. A second Safety Advisory Notice, to maintainers of piston-engine aircraft, highlighted the importance of the thorough inspection of exhaust systems and the timely repair or replacement of deteriorated components.
Additionally, the Civil Aviation Safety Authority (CASA) published an Airworthiness Bulletin(Opens in a new tab/window), which encouraged operators and maintenance organisations to initiate a periodic CO detection check to measure the level of CO in the cabin at each annual or 100 hours-time in service (whichever occurs first), and each time the exhaust system or related components are disturbed.
The CO level entering the cabin must be less than 1 part in 20,000 parts of air (equivalent to 50 parts per million), derived from FAA FAR 23.83.
The ATSB's 'Know CO' campaign, launched in December 2021, encourages the use of CO detectors with an active warning. These inexpensive and widely available devices can provide pilots with the best opportunity to detect CO exposure before it adversely affects their ability to control the aircraft, or they become incapacitated.
It is worth noting that in July 2023, the UK Civil Aviation Authority (CAA) published its report into a study on how low-cost, commercial off-the-shelf, carbon monoxide CO detectors with attention-getting capabilities performed in a variety of general aviation (GA) aircraft and operating conditions.
Following a review in 2020 of accidents and incidents in the UK by the Air Accidents Investigation Board (AAIB) which identified two fatal accidents, each with two fatalities, and fifteen other events where CO may have been a causal factor over a 20-year period, a was established to qualitatively and quantitatively investigate how low-cost active detectors perform in UK GA aircraft over a full flying season, to better understand pilot’s user experience of flying with these devices and to evaluate CO levels in a cross-section of the fleet.
Findings from the study suggested the risk of CO exposure remains a persistent background threat throughout the year and is somewhat elevated during cold weather operations. Anecdotal test evidence suggested that active CO detectors designed for domestic use can function reasonably at typical recreational GA altitudes (up to 5,000 feet).
The report highlighted that while effective maintenance remains the first line of defence against CO and is the only way to avoid exposure, choosing to fly with an active CO detector is a decision pilots can make to protect themselves and their passengers from CO should maintenance fail.
With a wide range of active CO detectors on the market it has never been easier for pilots to find a device that suits their needs and budget. Active CO detectors are increasingly being built into other aviation equipment as standard, including ADS-B and headsets, making them ever more prevalent in GA aircraft. Additionally, some active CO detectors can be paired to personal electronic devices such as smartphones and smartwatches, increasing the likelihood of being alerted to elevated CO levels.
The report also highlighted the risk of CO poisoning may be known and understood by many pilots, the same cannot be said for consumers and third parties generally, who may fly in piston engine aircraft on a commercial or recreational basis. Pilots therefore should consider the significant safety benefits offered by flying with an active CO detector – it could not only save their life, but their passengers’ as well.
Flying his Mooney, Dan Bass was overcome by CO poisoning and lost consciousness while airborne. He recounts the dreadful accident and his miraculous survival waking up in a snow-covered field in the bitter north American February cold.
New Zealand Airline Academy sees immediate value of electronic CO detectors
On 29 March 2020, an IAI Westwind II 1124A aircraft registered RP-C5880, on an aeromedical flight from Ninoy Aquino International Airport, Manila, Philippines was destroyed following a runway excursion during take-off from RWY 06. The eight occupants received fatal injuries.
The Civil Aviation Authority of the Philippines – Aircraft Accident Investigation and Inquiry Board (AAIIB) requested assistance from the Australian Transport Safety Bureau (ATSB) to download the aircraft’s cockpit voice recorder (CVR) and flight data recorder (FDR) to assist their investigation.
To facilitate this support and to provide the appropriate protections for the information, the ATSB appointed an accredited representative in accordance with paragraph 5.23 of ICAO Annex 13 and commenced an investigation under the Australian Transport Safety Investigation Act 2003.
On 15 October 2020, the fire-damaged recorders from RP-C5880 (Universal Navigation Corporation CVR-30 and Fairchild Model F800 FDR) arrived in Canberra. The CVR and FDR were successfully downloaded at the ATSB data recovery facility. This activity was performed by ATSB recorder specialists in conjunction with AAIIB investigators located in the Philippines. All data recovered from the recorders was provided to the AAIIB to assist with their Annex 13 investigation. A report detailing the results of the download of the recorders was provided to the AAIIB on 18 July 2021.
Figure 1: Universal CVR-30 cockpit voice recorder recovered from RP-C5880 on arrival at ATSB
Source: ATSB
Figure 2: Fairchild Model F800 flight data recorder recovered from RP-C5880 on arrival at ATSB
Source: ATSB
The Philippines AAIIB is responsible for the investigation and release of the final investigation report regarding this accident. Any enquiries regarding the investigation should be addressed to the Philippines Aircraft Accident Investigation and Inquiry Board at the contact details listed below:
