Why the ATSB did this research

Stall warning events have always been an area of interest for airlines and aviation safety investigators as they indicate that an aircraft is operating at the margins of safe flight. As these occurrences are reportable to the ATSB, the ATSB can analyse trends across airlines and Australia. By publishing such analysis, it is hoped that the wider aviation industry will be able to learn from the experience of others.

What the ATSB found

A review of 245 stall warnings and stall warning system events reported to the ATSB over a 5–year period showed that almost all were low risk events which were momentary in duration, and were responded to promptly and effectively by the flight crew to ensure positive control of the aircraft was maintained. No occurrences resulted in a stall or an irrecoverable loss of aircraft control, and only a few were associated with minor injuries to passengers or crew (generally those that occurred in severe turbulence) or a temporary control issue.

About 70 per cent of stall warnings reported to the ATSB were genuine warnings of an approaching stall, with the remainder being stall warning system problems. In only a minority of cases were system problems reported that resulted in false or spurious stall warnings such as a stick shaker activation.

Stall warnings (and in particular stick shaker activations) were well reported by Australian air transport operators, and occurred in a range of flight phases and aircraft configurations, not exclusively those related to low speed, high pitch attitude flight, or flight in poor meteorological conditions. Fifty-five per cent occurred in visual (VMC) conditions, and those in instrument (IMC) conditions mostly occurred in cruise. In typical stall warning events during cruise, the aircraft was operating at an altitude where there was a narrow band (about 20 knots) between the maximum operating speed and the stall warning speed (VSW). Common precursors to these events were rapid changes of pitch angle or airspeed. In about one-fifth of these occurrences, the stall warning system was activated when the autopilot tried to correct the aircraft’s speed or flight path due to a disturbance. Stall warnings during VMC flight were most common on approach, often involving aircraft being affected by turbulence while manoeuvring around weather.

The ATSB identified 33 serious and higher risk incidents in which a stall warning occurred. The majority of these involved brief stick shaker activations, and were associated with moderate or severe turbulence. Most happened on approach to land, when aircraft were in a low speed, high angle of attack configuration, and in several cases the stall warning speed was higher than normal (due to a higher wing loading (g) factor in a turn, or an incorrect reference speed switch setting). In these cases, the risk of a stall developing was increased by a lack of awareness of decreasing airspeed and increasing angle of attack prior to the stall warning, and/or an approach to land where the flight crew were focused on trying to correct the approach prior to the stabilised approach height instead of conducting a go-around.

Safety message

Stall warnings occur in normal operations, and are normally low risk events. In Australia, even the most serious events have not resulted in a loss of control, and have been effectively managed by flight crew to prevent a stall from occurring. To avoid higher risk stall warning events, pilots are reminded that they need to be vigilant with their awareness of angle of attack and airspeed, especially during an approach on the limits of being stable.

Introduction

At night, less can be seen outside the cockpit to help you control your aircraft. Although flight instruments are used under both Night Visual Flight Rules (VFR) and Instrument Flight Rules (IFR), at some stage during a night flight you will also need to fly the aircraft with reference to what can be seen outside.

What can be seen outside an aircraft at night varies greatly between the almost day-like conditions of flying over a city under a full moon to the complete darkness of remote areas without any moon or significant ground lighting. Safe flight relies on pilots applying the correct flying skills using the combination of information from flight instruments and from outside the aircraft.

Many pilots fly mostly in daylight. Night flying, even when undertaken by appropriately qualified pilots, presents an added level of complexity. In most cases pilots who operate at night have the necessary knowledge and skills and are flying suitably equipped aircraft.

A pilot who is qualified to fly visually at night should have the extra skills and equipment to control the aircraft by using flight instruments and by using more detailed flight procedures. Safe night visual flight requires the application, use and integration of all the information sources correctly. Compared with day visual flight, there is more to night visual flight than meets the eye.

Key message

The extra risks inherent in visual flight at night are from reduced visual cues, and the increased likelihood of perceptual illusions and consequent risk of spatial disorientation. These dangers can, however, be managed effectively. This report explains how suitable strategies can significantly reduce the risks of flying visually at night.

• Night flying is more difficult than flying in the day. Ensure you are both current and proficient with disciplined instrument flight. Know your own personal limitations in terms of flying with minimal or no visual references. Only fly in environments that do not exceed your capabilities.
• Before committing to departing on a visual flight at night or close to last light, ensure your aircraft is appropriately equipped and consider all obtainable operational information, including the availability of celestial and terrestrial lighting.
• Some nights and some terrain are darker than others. Excellent visibility conditions can still result in no visible horizon or contrast between sky and ground. Inadvertently flying into instrument meteorological conditions (IMC) is also harder to avoid at night.
• Always know where the aircraft is in relation to terrain and know how high you need to fly to avoid unseen terrain and obstacles.
• Remain aware of illusions that can lead to spatial disorientation—they can affect anyone. Know how to avoid and recover from illusions by relying on instrument flight.

The Aviation Short Investigation Bulletin covers a range of the ATSB’s short investigations and highlights valuable safety lessons for pilots, operators and safety managers.

Released periodically, the Bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken. The Bulletin also highlights important Safety Messages for the broader aviation community, drawing on earlier ATSB investigations and research.

Issue 23 of the Bulletin features 13 safety investigations:

Jet aircraft

• Abnormal engine indications involving a Boeing 747-438, VH-OJS
• Weather related event involving a Boeing 737, VH-YFF
• Departure from an incorrect intersection involving an Embraer ERJ 190, VH-ZPC
• Two turbulence events involving a Boeing 737, VH-VZY and a Bombardier DHC-8-402, VH-QOP
• Loss of separation between an Airbus A320, VH-VFJ and a Bell 412, VH-VAO

Turboprop aircraft

• TCAS event between an ATR72, VH-FVH and a Bombardier DHC-8-315, VH-TQZ
• Turbulence encounter involving a Bombardier DHC-8-402, VH-QOD

Piston aircraft

• Wheels up landing involving a Cessna 210, VH-ZMT
• Collision on the ground involving a Cessna 172R, VH-IMS

Helicopters

• Power loss involving a Robinson R44, VH-ZON
• Total power loss involving a Bell 47G2A, VH-KHJ
• Hard landing involving a Bell 206B, VH-EPQ
• Loss of control involving a Robinson R22, VH-EGN

Why have we done this report

Thousands of safety occurrences involving Australian-registered and foreign aircraft are reported to the ATSB every year by individuals and organisations in Australia’s aviation industry, and by the public. The aim of the ATSB’s statistical report series is to give information back to pilots, operators, regulators, and other aviation industry participants on what accidents and incidents have happened, how often they are happening, and what we can learn from them.

What the ATSB found

In 2012, there were 107 accidents, 195 serious incidents, and over 7,300 incidents reported to the ATSB involving Australian (VH– registered) aircraft, and a further 570 occurrences that involved foreign-registered aircraft operating within Australia or its airspace.

Commercial air transport aircraft were involved in the majority of incidents reported each year, and in 2012 the most common safety incidents reported were animal strikes, non-compliance with publish information or air traffic control instructions, and aircraft system and airframe issues. Most accidents and serious incidents related to reduced aircraft separation and engine malfunction.

General aviation aircraft, such as aircraft conducting flying training, aerial work, or private/pleasure flying, were involved in 38 per cent of occurrences reported to the ATSB in 2012. Airspace incursions, compliance with air traffic control, and birdstrikes were the most common incidents reported, with most accidents and serious incidents involving terrain collisions, engine failures, and a loss of aircraft control. Private/business operations had the highest number of fatal accidents in 2012 out of any year in the last 10 years, with 15 fatal accidents resulting in 22 fatalities. In contrast, commercial aerial work operations recorded the lowest number of accidents in the past 10 years.

In most operation types, helicopters had a higher rate of accidents and fatal accidents than aeroplanes.

A new addition to the ATSB’s aviation statistics are data on recreational (non–VH) aircraft safety. In 2012, the majority of the 274 occurrences reported were controlled airspace incursions, engine malfunctions, aircraft control problems, and runway events such as veer-offs.

Over the past 10 years, aerial agriculture had the most accidents and fatal accidents per hour flown, followed by private/business operations. Aerial survey and aerial mustering had the next highest accident and fatal accident rates.

Safety message

Aviation occurrence statistics provide a reminder to everyone involved in the operation of aircraft that accidents, incidents, and injuries happen more often than is widely believed. Some of the most frequent accident types are preventable, particularly in general aviation. Pilots and operators should use the misfortunes of others to help identify the safety risks in their operation that could lead to a similar accident or serious incident.

Timely and thorough reporting of safety incidents is paramount. The ATSB’s capability to understand why accidents and incidents happen and to identify the major safety risks in different types of aviation operations is at its best when all aviation participants report all safety incidents. The information the ATSB provides helps everyone in the aviation industry to better manage their safety risk.

Why the ATSB is doing this research

One of the main objectives of air traffic services (ATS) is to prevent the collision of aircraft. Aircraft separation standards are set to ensure that the chance of a mid-air collision is very remote. When they are infringed, there are fewer defences left to guard against a mid-air collision. This ATSB research investigation looks at loss of separation (LOS) incidents in Australian airspace to understand how often they occur and in what contexts, how and why they are occurring, and whether there are any wider implications that the air traffic system is not functioning appropriately.

What the ATSB found

Although there had been an increase in the number of occurrences reported to the ATSB over the 2 years ending in June 2012, there were fewer LOS occurrences during that period than during 2005 to 2008. Traffic levels have generally increased during the same period. A LOS between aircraft under air traffic control jurisdiction happens on average about once every 3 days. In almost 90 per cent of LOS occurrences, there was no or minimal risk of aircraft colliding. On average, however, there are six occurrences per year where an elevated risk of collision exists. There have been no mid-air collisions in Australia between two aircraft under ATS control.

The investigation found that military controlled terminal area airspace in general, and all airspace around Darwin and Williamtown in particular, had a disproportionate rate of LOS (for civilian aircraft). Most of these LOS occurrences were contributed to by air traffic controller actions. This may be a result of the nature of aircraft operations and airspace constraints at some military airports, leading to reduced use and effectiveness of strategic separation defences, thereby placing more responsibility for separating aircraft directly onto the controllers. Furthermore, as military ATS are not subject to safety oversight by the Civil Aviation Safety Authority (CASA), there is no independent assessment and assurance as to the safety of civilian aircraft operations at military airports.

In civil airspace, LOS occurrences attributable to pilot actions are not monitored as a measure of airspace safety nor actively investigated for insight into possible improvements to air traffic service provision. As about half of all LOS incidents are from pilot actions, not all available information is being fully used to assure the safety of civilian airspace.

What's been done as a result

The ATSB has issued recommendations to the Department of Defence to review all processes and controls in place for aircraft separation in military ATS and to CASA to review whether its current level of involvement with military ATS is sufficient to assure the safety of civil aircraft operations. The ATSB also recommends using all available information, including pilot attributable LOS occurrences, to assure the safety of civilian airspace, and will itself investigate all serious LOS incidents.

Safety message

Aircraft separation is a complex operation with many levels of defences to avoid errors and to safely manage the results of the errors that will inevitably be made from time to time by air traffic controllers and pilots. The defences ensure that even if a LOS does occur, the chance of an aircraft collision is still very remote. Safety could be enhanced through understanding and addressing the reasons for the disproportionate rate of LOS occurrences involving civil aircraft in military airspace, and through the ongoing monitoring and investigation of all LOS incidents in civil airspace.

Introduction

The Australian Transport Safety Bureau (ATSB) 2012–13 Annual Report outlines performance against the outcome and program structure in the 2012–13 Infrastructure and Transport Portfolio Budget Statements. 

Chief Commissioner’s review 2012–13

2012–13 was the ATSB’s fourth year in its current form as a fully independent agency within the Infrastructure and Transport portfolio. It has been a productive year. Our investigations yielded a range of important safety messages that touched every element of transport, from the manufacturing of vehicles through to the effectiveness of operators’ systems and the routine procedures used in the course of a working day. Especially satisfying has been the conclusion of several unusually large and complex investigations.

It was also a year in which we developed as an organisation, moving beyond the consolidation of our business systems and governance arrangements, and devoting more of our attention to enhancing our systems and capabilities. By improving and expanding these resources, the ATSB is able to bring a better perspective to bear—both on transport safety in Australia and on our own operations. We can now identify safety trends sooner, gauge the implications more thoroughly, and share our insights with the transport community more quickly and more directly.

One of the most significant improvements has been the augmentation of our enterprise system, the Safety Investigation Information Management System (SIIMS). SIIMS is an electronic management system that captures and organises information about transport accidents, tracking them from the point of notification through to the completion of investigation. The new version gives our investigators additional tools to manage their work while affording our managers greater visibility of our work on hand. This will help us to plan and manage our workloads more effectively and to gauge the implications of shifting priorities as new issues requiring investigation emerge.

We have also developed an automated event risk classification system. This will assign a risk to every aviation occurrence reported to the ATSB, based on the type of operation and type of occurrence. The event risk ratings are used in a number of ways. In 2012–13 ratings were provided twice a day to managers for every immediately reportable matter and all notable routine reportable matters in order to assist in their decisions whether to initiate investigations.

We have further developed our capability to analyse our statistical information and to identify worrying trends. We are now sharing these new insights with important stakeholders in the industry in quarterly bulletins.

Finally, while our investigators have proven themselves capable of unravelling the most complex of events (and machinery), we know that the greatest insight in the world is worthless if it is not applied. Our mission is not only to investigate safety, but to share what we have learned with the transport community. In the past year, we have worked to advance the ways in which we disseminate our message. A focus on strategic communications has helped us to improve the clarity of our investigation reports so that they can be better understood by readers without technical knowledge.

Users of smartphones and other mobile devices are now able to view our website easily, thanks to the application of advanced web technology and our use of social media. 

Aviation

The aviation investigation teams completed 43 complex and 99 short aviation accident and incident investigations during the past year. Several of these garnered considerable national and international interest. Key accomplishments included the completion of one of the largest and most complex investigations in our organisation’s history, the uncontained engine failure on a Qantas A380 over Batam Island, Indonesia, which occurred on 4 November 2010 (AO-2010-089); pursuing the issue of potentially dangerous fuel tanks in Robinson R44 helicopters; and spelling out the implications of the fatal accident involving an air ambulance rescue operation in the Budderoo National Park near Wollongong, NSW.

The completion of the Qantas A380 investigation is a matter of particular satisfaction. After the initial discovery of the fatigue-cracked oil feed stub pipe that led to the engine failure, we continued to work with the engine manufacturer, Rolls-Royce, to confirm how the manufacturing fault had occurred and how to revise their procedures to prevent recurrence. We also worked with Airbus and international regulators to highlight the implications of the accident for airframe certification standards. Our report, released on 29 June 2013, was the culmination of two and a half years of hard work and cooperation with other agencies, and spelled out issues with significant implications for air safety around the world.

The past year also saw the resolution of a different safety issue, one that tragically claimed several lives. We investigated three accidents in Australia involving post-accident fires in R44 helicopters. This led us to reinforce previous warnings to operators about the need to replace rigid aluminium fuel tanks by the deadline of 30 April 2013. As a consequence, the Civil Aviation Safety Authority (CASA) issued an Airworthiness Directive that effectively grounded any remaining R44s that had not complied by the deadline.

Another significant accident involved an air ambulance helicopter, where paramedics were winched from the aircraft to rescue an injured canyoner. During the winching, a paramedic and the canyoner fell on to some rocks and the paramedic was fatally injured. Following the investigation, the Ambulance Service of New South Wales and the helicopter operator took safety action in respect of the operating scope applied to retrieval operations and procedures used by helicopter emergency crews. In addition, paramedics, in their role as ambulance rescue crewmen, are now required to conduct annual night winching currency training.

The release of our investigation report into the ditching of the Westwind Jet at Norfolk Island that occurred on 18 November 2009 (AO-2009-072) became a subject of the ABC’s 4 Corners program and was commented upon by other media outlets. A review of the investigation by a Senate Committee was launched late in 2012. The ATSB was required to make a number of detailed submissions, provide a great many documents and attend a number of hearings at Parliament House. The enquiry report was released on 23 May 2013. The Commission has carefully considered the report and has developed an action plan in response to matters raised in the report. The Australian Government is considering its response to the Committee.

Marine

The Marine Investigation team completed 11 investigations during the year, two of which were particularly significant for safe work in and around ships. The first concerned the grounding of the general cargo ship Tycoon at Flying Fish Cove on Christmas Island (MO-2012-001). Our findings on that accident have delivered important safety messages to the managers of the port. Following this incident, the port operator commenced a program of inspections, replaced important equipment and developed a handbook and safety training.

The second accident reinforced the ATSB’s ongoing concern about the safety of stevedores and crew members on board cargo ships, an issue tragically exemplified by the death of a stevedore who was crushed by aluminium ingots on board Weaver Arrow (MO-2012-010). The accident has resulted in safety actions intended to address the handling of such cargo as well as the issue of stevedore fatigue.

We also issued a highly significant report which made important recommendations about the safety of coastal pilotage in Queensland coastal waters (MI-2010-011). This is particularly topical as Australia sees the development of port facilities and the increasing transit of shipping carrying coal and gas along these sensitive regions, including the Great Barrier Reef.

Rail

From 20 January 2013, the ATSB assumed primary responsibility for rail investigations across Australia, as part of the new national system for rail safety. This expanded national role in rail transport safety reflects the progressive implementation of the August 2011 Intergovernmental Agreement on Rail Safety Regulation and Investigation Reform. As the national system is implemented in each State, the ATSB is assuming its expanded role there as the rail safety investigator. Since January, we have worked collaboratively with our state and territory colleagues to ensure adequate resources are or will be available to respond quickly and efficiently to safety events as they occur. The Rail Investigation Team completed six complex and three short investigations during the year.

Safety priorities

Last year, for the first time, the Commission identified eight safety priorities for the coming year.  These represent major risk areas that need ongoing and heightened attention from the Australian transport community:

• General aviation pilots—General aviation (GA) pilots continue to die in accidents that are mostly avoidable. Prominent among these accidents are those that involve low flying, wirestrikes, flying visually into bad weather, mismanagement of partial power loss and poor fuel management.
• Handling approach to land—There are a worrying number of cases where stability is not adequately assessed or uncommon manoeuvres are mishandled during an aircraft’s approach to land.
• Data input errors—Human error involving incorrect data entry continues to cause concern.
  In some cases, aircraft systems and operators’ flight management procedures are not catching these errors.
• Safety around non-towered aerodromes—Non-towered aerodromes continue to pose a risk to aircraft due to poor communication between pilots, ineffective use of see-and-avoid techniques and failure to follow common traffic advisory frequency (CTAF) and other procedures.
• Robinson R44 fuel tanks—A significant number of R44 helicopters were not fitted with bladder-type fuel tanks and other modifications detailed in manufacturer’s documentation that are designed to provide for improved resistance to post-impact fuel leaks and enhanced survivability prospects in the event of an accident.
• Under-reporting of occurrences—An ATSB investigation during 2011–12 into under-reporting of wirestrikes revealed approximately 40 per cent under-reporting of incidents and accidents. While there are a range of factors that could influence under-reporting of this particular occurrence type, it is likely that there is under-reporting of other occurrences, particularly those associated with GA operations.
• Safe work on rail—The ATSB has investigated several accidents that have occurred when maintenance work was being carried out on or near railway tracks. Conducting work on or near a railway track can be dangerous if safe working rules and procedures have not been correctly implemented to protect the worksite.
• Marine work practices—The ATSB has investigated several incidents involving unsafe working practices in the maritime industry. These incidents resulted in serious injury of death following falls from heights, crush, and equipment that exploded.

Upon release of our report (MI-2010-011) into Queensland coastal pilotage in October 2012, we added this as a further risk area. In order to publicise our concerns, and educate stakeholders about what they can do to improve their own safety, we developed a communications initiative, SafetyWatch. SafetyWatch is featured on the ATSB website and forms the focus for our industry and stakeholder engagement.

Outlook for 2013–14

Last year I commented that, with 56 larger aviation investigations on hand at the end of the financial year, we had reached what I judged to be a sustainable level of activity that was allowing us to meet our targets for timely investigations while maintaining the high quality of our work. We conclude this year with 65 larger aviation investigations on hand. This higher number reflects the level of resources we had to apply to our more complex investigations and some unplanned activities such as the Senate Inquiry. It also reflects that we are not fully meeting our performance standards for delivering investigations in a timely fashion. As we report elsewhere, more work needs to be done to improve the timeliness of our investigation reporting.

Like most government agencies, we are subject to the resource constraints imposed by the government’s efficiency and savings initiatives. This, combined with our work on the implementation of the National Rail Reforms and the new responsibilities they have brought, resulted in a year in which heavy commitments meant that we had to divert resources from other investigations with consequent delays.

The ATSB has never been resourced to undertake investigations into every accident or incident that occurs. Rather, it is necessary for us to be strategic, investigating those accidents and incidents that are likely to yield safety improvements for transport operators and the travelling public.

We can expect to continue to work in a resource-constrained environment during the foreseeable future and will need to be creative in finding ways to deliver the high quality expected by the government and the Australian public. Our responsibilities have grown in the rail sector and we are also acutely conscious of the effect on our available resources of the demands of one or more complex investigations.

More than ever we will need to be selective in deciding what matters to investigate in order to achieve the greatest value and confidence for the travelling public. Under current and forecast resource limits, a time is approaching when we will have to be more constrained as to which investigations and activities we can undertake and as to the extent of those investigations we do undertake. While we will continue to take all possible steps to mitigate it, the risk that we will miss an important issue increases as our resources diminish.

We continue to remain alert and prepared to handle a major accident in aviation, marine or rail and recognise the exceptional effort that would be required to respond. To ensure that we remain alert and responsive, our staff members continue to participate in planning and exercises and we continue to learn from our overseas counterparts.

We also continue to work with our neighbours in the region and to be an active and constructive player in the International Civil Aviation Organization, the International Maritime Organization and other international forums that have a role in transport safety. I am pleased that we have been able to assist our neighbours in the region during the year, using development cooperation funding from AusAID.

While the times are challenging, I remain enormously proud of the dedication and the accomplishments of our investigators and other staff. The technical knowledge and expertise within the ATSB is world-class. I thank the investigation and supporting staff of the ATSB whose efforts and expertise consistently enable us to provide an essential service to the Australian travelling public.

Martin Dolan
Chief Commissioner/CEO 

• Download:
  ATSB Annual Report 2012-13 (5.03 MB)

Why have we done this report

Significant debate has occurred within the aviation industry regarding the issues of pilot training and experience, particularly with regard to the introduction of new pilot training programs that are focused on training cadet pilots. The main concern being presented by some sectors of the industry that are not in favour of these concepts is that these low-hour co-pilots are not as competent as their high-hour peers.

The ATSB gathered data from three airlines to explore the issue of pilot performance as a function of both flight hour experience, and entry pathway. Entry pathway analysis compared cadet pilots (who generally had not accumulated prior flight hours or experience) to those pilots who entered an airline after accumulating flight hours in other areas of the aviation industry.

Data were collected on a number of metrics from simulator check flights, which covered non-normal operations, and line checks, which covered normal day-to-day flight operations.

What the ATSB found

The overall performance of cadets and low-hour pilots matched that of their direct entry and high-hour peers. All pilots were marked as proficient at the completion of the check flights, with the only differences between the groups being a function of how many exceeded the required standard.

The differences between the low and high-hour pilots in ‘meeting’ and ‘exceeding’ the standard across all metrics were variable within airlines and inconsistent across all three airlines. This suggests that the differences between the groups were not of a systemic nature that would highlight an area of concern for industry. While the metric normal landing showed a difference across two of the three airlines, none of the other required regulatory manoeuvres or technical metrics were significantly different in more than one airline. For non-technical metrics, both leadership and situation awareness were significantly different in all three airlines. Although this is understandable given the low experience of cadet and low-hour pilots, focused exposure to those metrics during initial airline training may reduce this difference as was seen in the data for cadets collected at the 5-year mark in one airline.

Safety message

The evidence in this report indicates that the cadet pathway for low-hour pilots is a valid option for airlines. There was no evidence to indicate that cadets or low-hour pilots within the airlines studied were any less competent or proficient than their direct entry and high-hour peers.

The Aviation Short Investigation Bulletin covers a range of the ATSB’s short investigations and highlights valuable safety lessons for pilots, operators and safety managers.

Released periodically, the Bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken. The Bulletin also highlights important Safety Messages for the broader aviation community, drawing on earlier ATSB investigations and research.

Issue 22 of the Bulletin features 11 safety investigations:

Turboprop aircraft

• Left main landing gear collapse involving a Raytheon B200, VH-ZCO
• Aircraft proximity event between a Fairchild SA227, VH-HVH and an Aerospatiale AS350, VH-JRJ

Piston aircraft

• Aircraft proximity event between two Cessna 172s, VH-EOE and VH-LWX
• Aircraft proximity event between a Piper PA-28, VH-TXH and a Cessna 172S, VH-EWX
• Operation below minimum safe altitude involving Aero Commander, VH-TQA
• TCAS warning between a Cessna 310R, VH-AEY and a Fokker F28-100, VH-FKJ
• Runway incursion involving a Piper PA-31, VH-KLS and a vehicle
• Total power loss involving a Mooney M20J, VH-NFP
• Aircraft proximity event between a Cessna 172, VH-WYG and a Cessna 185, VH-OZX

Helicopters

• Collision with terrain involving a Bell 412, VH-EMZ
• Aircraft proximity event between a Janus glider, VH-IZI and a McDonnell Douglas 500N, VH-KXS

The Aviation Short Investigation Bulletin covers a range of the ATSB’s short investigations and highlights valuable safety lessons for pilots, operators and safety managers.

Released periodically, the Bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken. The Bulletin also highlights important Safety Messages for the broader aviation community, drawing on earlier ATSB investigations and research.

The Aviation Short Investigation Bulletin, Issue 19 features nine safety investigations:

Jet aircraft

• Take-off without runway lighting involving Airbus A320, VH-JQG

Turboprop aircraft

• Runway incursion between a Fairchild SA227, VH-WBA and a vehicle
• Loss of ground control involving a PZL-Mielec M18A Dromader, VH-TGY

Piston aircraft

• Collision on ground involving Cessna 150F, VH-ICE
• Landing on a closed runway involving a Cessna 310, VH-TWN
• Runway incursion between a Cessna 206, VH-TOC, and an airport safety vehicle
• Collision on runway between Grob G103 Twin Astir glider, VH UIZ and Cessna 150F, VH ROZ
• Wildlife strikes involving a Mooney M20J, VH-CYK

Helicopters

• Wirestrike involving Robinson R44, VH-HGF

The Aviation Short Investigation Bulletin covers a range of the ATSB’s short investigations and highlights valuable safety lessons for pilots, operators and safety managers.

Released periodically, the Bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken. The Bulletin also highlights important Safety Messages for the broader aviation community, drawing on earlier ATSB investigations and research.

The investigations Issue 20 of the Bulletin features ten safety investigations:

Turboprop aircraft

• Weight and balance event involving Fairchild SA-227AC, VH-UUO

Piston aircraft

• Landing gear separation involving Piper PA28, VH-JXR
• Wheels up landing involving Cessna 210M, VH-PBV
• Collision with terrain involving Grob G-115, VH-ZTM
• Aircraft proximity event between a Piper PA-44, VH-TYS and a Cessna 172S, VH-EUH
• Landing gear collapse involving Piper PA-30, VH-HPR
• Wheels up landing involving Piper PA-24-260, VH-DRB
• Weather related precautionary landing involving a Piper a PA-28, VH-MSG

Helicopters

• Collision with terrain, involving AS350, VH-EWM
• Wirestrike involving Enstrom 480B, VH-VDC