ATSB releases Mangalore mid-air collision investigation final report

Key points:

• Two twin-engine training aircraft collided mid-air near Mangalore Airport, Victoria fatally injuring four pilots;
• Both aircraft were flying in non-controlled airspace at the time of the collision;
• ATSB supports systemic enhancements to the overall Australian air traffic system that have been assessed by regulatory and air traffic specialists as providing a net overall safety increase;
• The ATSB strongly encourages the fitment and use of Automatic Dependent Surveillance Broadcast (ADS-B) avionics, with some equipment currently available within Australia at low cost and can be used without any additional regulatory approval or expense.

The Australian Transport Safety Bureau has released the final report from its investigation into the mid-air collision between two training aircraft near Mangalore, Victoria, on 19 February 2020, identifying contributing safety factors to the accident relating to self-separation in non-controlled airspace.

The report details that shortly before 11.00am, a twin-engine Beech Travel Air departed from Tyabb Airport for a return Instrument Flight Rules (IFR) training flight to and from Mangalore Airport – a non-controlled airport in Class G airspace – with a student pilot and an instructor onboard. At around the same time, a pilot under examination and flight examiner were at Mangalore Airport preparing for an instrument rating flight test in a twin-engine Piper Seminole.

While the Travel Air was on descent and the Seminole was on climb, the two aircraft collided at an altitude of around 4,100 feet about 8 km (4 nm) south of Mangalore Airport. Tragically, all four pilots were fatally injured and both aircraft were destroyed.

Prior to the collision, the pilots of each aircraft had been provided with traffic information about the other aircraft, in accordance with procedures, by an air traffic controller in Melbourne Centre. In addition, other pilots monitoring the common traffic advisory frequency (CTAF) radio channel for the Mangalore area reported hearing pilots from both aircraft make radio broadcasts, but had no recollection of hearing them speaking directly to each other.

The accident was the first mid-air collision in Australia between two civilian aircraft operating under IFR procedures that have been in place for many decades.

“The ATSB identified that, following receipt of verbal traffic information provided to both aircraft by air traffic control, the pilots did not successfully manoeuvre or establish direct radio communications to maintain separation, probably due to the collision risk not being recognised,” said ATSB Chief Commissioner Angus Mitchell.

“The investigation also determined that while it is probable the aircraft were in instrument meteorological conditions at the time of the collision, due to extensive cloud in the area, the known limitations of the ‘see-and-avoid’ principle meant that the pilots were unlikely to have seen each other in sufficient time to prevent the collision even in clear weather.”

In non-controlled airspace, irrespective of whether an aircraft is operated under instrument or visual flight rules, pilots are responsible for separation from other aircraft.

“As such, if made aware of traffic, either via advice from air traffic control, a received broadcast, or any other means, it is vitally important for pilots that the traffic is hazard assessed and, if necessary, a plan is established to assure separation.”

Mr Mitchell stated that self-separation using broadcast traffic advice is subject to human error, even when it involves experienced pilots.

“The ATSB notes that had the aircraft been operating in controlled airspace, they would have been positively separated by air traffic control, and therefore the collision would have been unlikely to have occurred, and while the available evidence in this investigation does not support a conclusion that the present system of self‑separation in Mangalore airspace is unsafe, there is an opportunity to reduce safety risk further.

“The ATSB supports systemic enhancements to the overall Australian air traffic system that have been assessed by regulatory and air traffic specialists, in keeping with their obligations, as providing a net overall safety increase.”

Mr Mitchell noted in this accident that while the pilots were responsible for self-separation within the Mangalore CTAF area, they did not have access to the same surveillance data radar or automatic dependent surveillance broadcast (ADS-B) information that was available to air traffic control.

“As a result, the pilots were required to make timely decisions to avoid a collision without the best available information,” he said

“Consequently, the ATSB strongly encourages the fitment and use of ADS-B transmitting, receiving and display devices in all general and recreational aviation aircraft, as these devices can significantly assist pilots with the identification and avoidance of conflicting traffic,” Mr Mitchell said.

ADS-B is a system which transmits GPS-derived position data, aircraft identification and other aircraft performance parameters. In Australia, all aircraft operating under the IFR are required to be fitted with ADS-B broadcast (or ADS-B OUT).

Both accident aircraft were fitted with ADS-B OUT, but neither aircraft was fitted with a system to receive ADS-B information directly from other aircraft (known as ADS-B IN), and nor were they required to be.

“The continuous positional information that ADS-B provides, when used with a relevant alerting capability enabled, can assist in highlighting a developing situation many minutes before it becomes hazardous – a significant improvement on both point-in-time radio traffic advice and ‘see and avoid’.”

Mr Mitchell noted that in December 2021, the Department of Infrastructure announced a $30 million fund to provide rebates to general aviation aircraft operators to fund up to $5,000 or 50% of the cost of installing ADS-B transponder technology into their aircraft.

“When details of that fund are finalised, the ATSB looks forward to further highlighting the benefits of ADS-B, and in particular ADS-B IN, to the aviation community.”

Read the final report: Mid-air collision involving Piper PA-44-180 Seminole, VH-JQF and Beech D95A Travel Air, VH-AEM, 8 km south of Mangalore Airport, Victoria, on 19 February 2020

More information about ADS-B and the benefits of using the technology:

The Australian Transport Safety Bureau has released the final report from its systemic investigation into a serious incident where a Malaysia Airlines Airbus A330 with 14 crew and 215 passengers on board took off from Brisbane Airport with no airspeed information.

Shortly after the aircraft arrived in Brisbane from Kuala Lumpur on 18 July 2018, a support engineer placed covers on the aircraft’s three pitot probes (airspeed sensors) to prevent them from being blocked by mud wasps, a known hazard at Brisbane Airport.

However, during the turnaround and before the aircraft departed for the return flight to Kuala Lumpur the covers were not removed. This was despite there being requirements for multiple walk-around checks by the aircraft captain, engineer and dispatch coordinator, all intended to identify unsafe conditions such as the fitment of pitot probe covers.

Consequently, the aircraft’s primary instrument displays showed red speed flags in place of airspeed indications from early in the take‑off, and the flight crew did not respond in time for the take-off to be safely aborted.

Once airborne the flight crew climbed the aircraft to 11,000 ft where they performed troubleshooting and other procedures, including shutting down the aircraft’s air data systems. This activated a system installed on some Airbus aircraft called the back up speed scale (BUSS), which displayed a safe flight envelope for flight crew to maintain.

Using the BUSS and airspeed management procedures, and assisted by air traffic control, the flight crew brought the aircraft safely back to Brisbane.

“At first glance, it may seem puzzling why multiple checks failed to detect the fitment of the pitot probe covers, or how the flight crew could complete take-off without any valid airspeed being displayed,” said ATSB Chief Commissioner Angus Mitchell.

“This led to the ATSB undertaking one of its most substantive and complex investigations in recent years.”

Mr Mitchell said the ATSB identified safety factors across a wide range of subjects including flight deck and ground operations, aircraft warning systems, air traffic control, aerodrome charts, and risk and change management.

“The investigation illustrates how a range of individually straightforward factors can combine to nullify multiple critical safety barriers,” he said.

On the night, several individuals from different organisations had separate, key roles in detecting aircraft damage or other unsafe conditions such as the fitment of pitot probe covers. However, these checks were omitted entirely or only partially completed, for a variety of reasons including inadequate communication and reduced diligence.

“Had all the relevant pre-flight inspections been completed, and conducted thoroughly, it is very likely that the pitot probe covers would have been seen and removed,” Mr Mitchell noted.

“It’s important to treat every safety-related task or inspection as though it could be the last barrier to protect against an accident.”

Malaysia Airlines had recently reintroduced flights to Brisbane, and although the wasp risk was identified, the use of pitot probe covers was not required or controlled. Shortly after the occurrence, the ATSB issued a safety advisory notice (SAN) to operators who fly to Brisbane Airport to consider the use of pitot probe covers and, where they are used, ensure there are rigorous processes for confirming they are removed before flight.

The ATSB also uncovered a range of deeper issues, including coordination among the involved organisations, that allowed front-line problems to emerge.

“Inconsistent approaches between multiple interacting organisations can have safety implications that are hard to predict,” Mr Mitchell observed.

For flight crew, the occurrence also highlights the importance of vigilance, communications, and decision-making in adverse circumstances.

The ATSB found that surprise, uncertainty, time pressure, and ineffective communication between the two pilots during the take-off probably led to stress and high cognitive workload. This reduced their capacity to interpret the situation and make a decision early enough to safely reject the take-off.

In response, the ATSB has issued a safety advisory notice (SAN) advising manufacturers and operators of all large transport aircraft to consider what types of unreliable airspeed events can occur, how the information is presented to pilots, and what responses are the safest in different phases of the take-off and in a range of potential situations.

All of the relevant organisations have contributed to the large number of safety actions taken in response to the incident and the ATSB’s investigation. For example, Malaysia Airlines now requires the placement of a placard on the flight deck as a visual alert that pitot probe covers are in place, and has introduced improvements to its change and risk management processes.

Airbus, meanwhile, has implemented additional flight crew training standards about unreliable airspeed on take-off, added guidance to the flight crew techniques manual on the importance of airspeed monitoring on take-off, and has commenced a review of airspeed indications in A330 and other aircraft types.

The ground handling and engineering companies involved in the incident have also made system and process improvements, and the airport information provided to pilots has been amended.

“The cooperation of all involved organisations has been very encouraging, especially the amount of safety action they have undertaken,” said Mr Mitchell.

“Many safety gaps have been addressed as a result of this extensive investigation.”

Read the final report: Airspeed indication failure on take-off involving Airbus A330, 9M-MTK, Brisbane Airport, Queensland, on 18 July 2018

The ATSB has released a preliminary report from its investigation into a fatal accident involving a Rockwell International 114 light aircraft

The ATSB has released a preliminary report from its on-going investigation into a fatal accident involving a Rockwell International 114 light aircraft near Redcliffe aerodrome, north of Brisbane, on 19 December 2021.

The report, which details factual information from the investigation’s early evidence collection phase, notes that the aircraft departed Redcliffe for a private scenic flight. On board were a pilot and three passengers.

“A number of witnesses located at the airport, in other aircraft, and on the water in boats, observed the accident aircraft take off and retract its landing gear,” ATSB Director Transport Safety Dr Michael Walker said.

“A short time later, witnesses reported that the engine ran rough briefly before stopping completely.”

Another pilot reported hearing the pilot of the accident aircraft broadcast on the radio that they were returning to the aerodrome, and the aircraft was observed to make two left turns, consistent with manoeuvring back to the runway, and extend its landing gear.

“As the aircraft neared the mangrove tree line to the north of the aerodrome, it was observed to descend and ditch into the water of a tidal mud flat, about 170 m from the shoreline,” Dr Walker said.

“During the ditching, the aircraft flipped over, coming to rest inverted in about 2 m of water.”

The pilot and three passengers were fatally injured in the accident and the aircraft was destroyed.

To date, ATSB investigators have recovered and examined the aircraft wreckage, conducted witness interviews, disassembled and examined the engine, reviewed the aircraft’s maintenance history, and examined security camera footage from the aerodrome.

“As the investigation continues, the ATSB’s investigation will include a disassembly and examination of the aircraft’s propeller, testing engine components, analysis of data recorded from onboard systems, and further analysis of available footage,” Dr Walker said.

“Should a critical safety issue be identified at any time during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.”

Read the preliminary report: Fuel starvation and collision with water involving Rockwell International 114, VH-WMM, 1km north of Redcliffe aircraft landing area, Queensland, on 19 December 2021

ATSB releases Moree aerial spraying accident preliminary report

The ATSB has released a preliminary report from its ongoing investigation into a fatal accident involving an Air Tractor AT-400 aerial application aircraft during spraying operations west of Moree, New South Wales, on 4 December 2021.

The report details factual information from the investigation’s early evidence collection phase and describes the aircraft’s operations conducting aerial spraying from an airstrip on a property 80 km west-south-west of Moree.

Over a period of approximately 5 hours, the aircraft took off from and landed at the airstrip, as the pilot sprayed ten hopper loads of chemical on designated areas of the property. These were sprayed using a racetrack pattern.

At 1126, the aircraft departed with the 11th load to spray an area adjacent to the property’s eastern boundary. During this flight the pilot used a back-to-back pattern, conducting a ‘procedure turn’ to reposition the aircraft on the reciprocal heading for the next spray run.

After the aircraft had completed the fourth parallel run, a witness located in the neighbouring paddock observed the aircraft enter a right procedure turn above trees.

“During the turn, the aircraft was observed to descend rapidly, right-wing down, and disappear behind the trees. The witness reported seeing a black plume of smoke rise almost immediately afterwards,” ATSB Director Transport Safety Dr Stuart Godley said.

The aircraft wreckage was subsequently located at the southern end of a stand of trees. The pilot had sustained fatal injuries and the aircraft was destroyed.

“ATSB transport safety investigators’ examination of the accident site found that the aircraft collided with terrain upright, in a slight nose down and right wing down attitude,” Dr Godley said.

“There were no powerlines in the area and there was no evidence of tree or bird strike.”

Examination of the damage to the engine and propeller blades was consistent with the engine producing power at impact. Where possible, investigators established continuity of the flight controls.

Dr Godley noted the ATSB’s preliminary report does not include any safety findings or analysis, which will be detailed in the investigation’s final report.

“As the investigation continues, the ATSB will examine electronic components recovered from the accident site, and review the pilot’s qualifications and experience, weather conditions, operational documentation and relevant regulations, and accident survivability aspects,” he said.

“Should a critical safety issue be identified at any time during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.”

Read the preliminary report: Collision with terrain involving Air Tractor AT-400, VH-ACQ 80 km west-south-west of Moree, New South Wales, on 4 December 2021

New CASA regulations do not impact on existing obligations to report safety occurrences to the ATSB

The Australian Transport Safety Bureau is stressing that the introduction of new Civil Aviation Safety Authority flight operations regulations do not impact on existing obligations to report safety occurrences to it.

The new CASA regulations took effect from 2 December 2021, and are relevant to all pilots and operators.

But they do not affect obligations to notify the ATSB of aviation accidents and incidents, as these are defined under the Transport Safety Investigation Regulations, and so are separate to CASA’s Civil Aviation Safety Regulations.

“Pilots’ and operators’ obligations to report accident and incidents to the ATSB remain unaffected by the introduction of the new CASA regulations,” ATSB Director Transport Safety Dr Stuart Godley said.

“When reporting occurrences to the ATSB we do ask that reporters be aware of the flight operations Civil Aviation Safety Regulation (CASR) Part relevant to your operation and include this in your reports to the ATSB.

“But your obligations to report occurrences are based on the type of operation defined in the Transport Safety Investigation Regulations which remain unchanged by CASA’s new regulation changes.”

Accidents and incidents which affect the safety of an aircraft must be immediately reported to the ATSB by telephone by calling 1800 011 034 (or if calling from outside Australia, +61 2 6230 4470). Less serious aviation occurrences – matters that have not had a serious outcome but transport safety was affected or could have been affected – can be reported to the ATSB online via our webform.

Obligations to report accidents and incidents are legislated under the Transport Safety Investigation Act 2003, which enable the Transport Safety Investigation Regulations.

Dr Godley noted that the ATSB anticipates undertaking consultation on updates to the reporting requirements in the Transport Safety Investigation Regulations during 2022, with a planned commencement date of revised regulations of 1 January 2023.

Pilot encountered pitch-up controllability issues after ground handlers estimated weight of relocated freight by feel

A Metro freighter aircraft’s pilot had to use forward pressure on the control column to maintain level flight after ground handlers estimated the weight of freight that was relocated into the aircraft’s nose by feel. This resulted in the aircraft’s centre of gravity falling outside of the rear limit, an Australian Transport Safety Bureau investigation into the occurrence details.

On 11 May 2020, the twin turboprop Fairchild Metro 23 aircraft, operated by Toll Aviation, was being loaded for a scheduled freight service from Townsville to Brisbane via Rockhampton, in Queensland.

Prior to take-off from Townsville, the pilot completed a load and trim sheet based on a load plan provided by the ground handling team.

A load and trim sheet is used to calculate the total weight on board, and to ensure the distribution of that weight does not shift the aircraft’s centre of gravity beyond lateral and longituidinal limits, which is critical to ensure stable, controllable flight.

The pilot’s calculation indicated the distribution of freight throughout the aircraft’s six main zones was too heavily weighted to the rear.

To address this, the pilot and ground handlers agreed 126 kg of freight would be moved out of the aircraft’s third zone compartment, and into the nose storage compartment.

“During this last-minute change, the ground handlers did not accurately weigh the freight being relocated, as there were no scales at the aircraft,” ATSB Director Transport Safety Dr Michael Walker explained.

“Instead, they estimated the mass of the freight by feel, and only actually moved around 65 kg of cargo.”

The resulting discrepency between the pilot’s planned load and trim sheet, and the actual load distribution on the aircraft, was not initially enough to put the aircraft’s centre of gravity outside the allowable limits.

However, when the aircraft landed in Rockhampton, more freight was loaded into the rear half of the aircraft, and the centre of gravity shifted further aft, beyond the allowable limit.

“On the second leg of the journey, the pilot reported the aircraft had a strong pitch-up tendency, and that strong forward pressure on the flight controls was required to maintain the correct pitch attitude,” Dr Walker said.

“During the cruise, the autopilot would not consistently maintain level flight. The pilot disconnected the autopilot and, with full nose-down trim applied, the pilot had to maintain forward pressure to control the pitch attitude of the aircraft.”

After landing safely in Brisbane, the pilot discussed the incident with ground maintenance engineers, and the freight from each compartment was reweighed as it was unloaded.

“The pilot subsequently completed a new load and trim sheet using the actual weights and the centre of gravity was found to be aft of the rear limit,” Dr Walker said.

Additionally, when accounting for the weight added in Rockhampton, the new data showed the aircraft was actually about 6 kg above its maximum take-off weight when it initially took off from Townsville, on the first leg of its journey.

Due to fuel burn during the first leg of the flight, the aircraft had come under its weight limit by the time it landed and took off in Rockhampton.

“This incident demonstrates the critical nature of load control,” Dr Walker said.

“It also emphasises the importance of providing ground handlers with sufficient and detailed procedures to allow them to accurately conduct load control duties and minimise the potential for error.”

The ATSB’s investigation found the operator’s ground handling manual did not contain detailed procedural guidance for facilitating accurate redistribution of freight and ensuring that an aircraft would be correctly loaded.

Following the incident, Toll amended its ground handling processes, and included increased direction to ensure that freight would be accurately redistributed in the event of a last-minute change.

Notably, the operator has since divested its flying operations to another operator, and relinquished its Air Operator’s Certificate.

The ATSB, in consultation with Toll, contacted the new aircraft operator to discuss the potential risk of a lack in procedural guidance for ground handling.

“Although the safety issue was not directly related to them, the new operator has reviewed their ground handling manual and incorporated amendments to address the safety issue,” Dr Walker concluded.

Read the final report: Aircraft loading and in-flight controllability issue involving Fairchild SA227, VH-HPE, Rockhampton Airport, Queensland, on 11 May 2020

Supporting World Maritime Day 2021 to help keep the world's seafarers safe

The United Nation’s World Maritime Day is an opportunity to highlight the professionalism and dedication of the 2 million seafarers who serve on the world’s merchant fleet.

Throughout the pandemic shipping has continued to transport vital medical supplies, food and other basic goods that are critical for the global COVID-19 response and recovery and highlighted the contribution of all seafarers as key and essential workers on the front line of delivering vital goods through a pandemic and in ordinary times.

This year World Maritime Day(Opens in a new tab/window) aims to raise awareness of seafarer’s crucial role in world trade and focus attention on their place at the core of the global shipping industry including their role in maritime safety.

The ATSB is deeply committed to improving maritime safety for seafarers through its ‘no-blame’ maritime accident investigations and safety messaging to industry and individuals to prevent future accidents. The ATSB also recognises and celebrates its transport safety investigators who began their careers at sea.  Ahoy!

To learn more about some of our more recent maritime investigations and their related safety messaging read the reports below. 

MO-2018-008: Loss of containers overboard involving YM Efficiency, 16 NM east-south-east of Newcastle, New South Wales, on 1 June 2018

MO-2018-009: Fatality in the elevator trunk on board OOCL Kuala Lumpur, 8.5 nautical miles south-east of Port Botany, New South Wales, on 3 June 2018

MO-2018-011: Fire on board Iron Chieftain, Port Kembla, New South Wales, on 18 June 2018 

New transport safety reporting requirements reflect growing importance of remotely piloted aircraft

The Australian Transport Safety Bureau will be better able to assess safety issues and monitor trends in the operation of remotely piloted aircraft (or drones), thanks to new reporting requirements.

On 30 September 2021, the Transport Safety Investigation Regulations 2003 will be repealed and replaced by the new Transport Safety Investigation Regulations 2021(Opens in a new tab/window). These new regulations will continue to require the reporting of certain transport safety occurrences to the ATSB as immediately or routine reportable matters.  The main changes to these regulations will be the introduction of updated requirements for operators of certain types of remotely piloted aircraft (RPA) to make reports to the ATSB.

“RPAs are an emerging form of commercial aviation that will benefit from investigation into systemic safety issues to help prevent future accidents,” said ATSB Chief Commissioner Angus Mitchell.

“The recognition of transport safety issues associated with the operation of RPAs, will be a welcome development, and provide greater certainty for commercial operators and enthusiasts alike.

“For the ATSB, it’s an exciting opportunity to apply our world-leading aviation safety investigation capabilities, and improve safety outcomes in a growing field.”

Recognising the range of different types of RPA and their uses, the regulations will categorise relevant RPA as type 1 or type 2 RPA.  RPAs that have been certified against relevant airworthiness standards (type certification), large (greater than 150kg) and medium RPAs (more than 25kg but not more than 150kg) are defined as type 1 and are an emerging form of commercial aviation that will benefit from investigation into systemic safety issues to help prevent future accidents.

In contrast, type 2 RPA are defined as those RPA that are not type 1, excluded or micro RPA (gross weight of not more than 250 grams) and will have fewer reporting requirements. This distinction is made on the basis that ATSB investigations are unlikely for these operations unless there is serious risk of harm to people or significant third-party property.

RPAs that are not type 1 or type 2 including excluded or micro RPA will have no reporting requirements under these regulations.

Mandatory reporting for certain occurrences involving type 1 and type 2 RPA (see below) will allow the ATSB to properly measure, investigate and report on safety trends in the RPA sector.

Making a report to the ATSB is not a time-consuming process, and the ATSB investigates incidents from a ‘no-blame’ perspective, prioritising improved safety outcomes.

Who is affected?

In order to provide an efficient and effective safety framework, the new regulations define two types of RPAs which will be subject to specific reporting requirements.

Type 1 RPAs are those which are type certified, large (over 150 kg) or medium (25 kg to 150 kg) RPA.

Type 2 RPAs are those that are not Type 1, and are not an excluded or micro (under 250 g) RPA.

Under the revised requirements, Type 1 operators will be required to immediately report to the ATSB RPA occurrences involving:

• death or serious injury;
• accidents;
• loss of a separation standard with aircraft; and,
• serious damage to property.

Less serious incidents and occurrences are required to be reported to the ATSB within 72 hours

Occurrences involving Type 2 RPAs will generally only need to be immediately report to the ATSB if they involve death or serious injury, while less serious incidents and damage to the RPA will need to be reported within 72 hours.

Reports can be made on the ATSB website, or by calling 1800 011 034.

About the ATSB

The ATSB contributes to transport safety by independently investigating, analysing and openly reporting on transport safety matters.

Each year the ATSB receives more than 17,000 notifications of transport incidents and accidents.

To prevent future transport safety occurrences, especially those with the potential for loss of life or serious injury, the ATSB directs its investigation resources to those incidents and accidents with the greatest potential of identifying systemic issues in aviation, marine and rail transport operations.

Read more: /about_atsb/overview/

Changes bring ATSB marine regulations up to date

Amendments to investigation regulations have revised the descriptions for the types of vessels that are required to report transport safety occurrences to the Australian Transport Safety Bureau.

On 30 September 2021, the Transport Safety Investigation Regulations 2003 will be repealed and replaced by the new Transport Safety Investigation Regulations 2021(Opens in a new tab/window). These regulations will update the descriptions for vessel types and reportable matters to align with terminology in the Navigation Act 2012.

The commencement of the new regulations will require the following vessel types to report certain occurrences to the ATSB:

• regulated Australian vessels (within the meaning of the Navigation Act) in the course of relevant marine navigation
• foreign vessels (within the meaning of the Navigation Act) in certain Australian waters and in the course of relevant marine navigation
• domestic commercial vessels, as defined in the Marine Safety (Domestic Commercial Vessel) National Law, that are on an interstate voyage.

The regulations will also align the types of occurrences that must be reported to the ATSB (as a reportable matter) under the TSI Regulations, with ‘marine incidents’ that must be reported to AMSA under the Navigation Act

“In practice, these amendments won’t change the process for reporting transport safety occurrences to the ATSB, and operators may continue to report occurrences directly to the Australian Maritime Safety Authority, who will forward the report,” ATSB Chief Commissioner Angus Mitchell said.

“These amendments will ensure that the Transport Safety Investigations Regulations are aligned with the terminology in the Navigation Act. The Regulations will continue to exclude domestic commercial vessels from these requirements, unless they are on an interstate voyage.”

Underwater helicopter escape highlights importance of emergency breathing systems 

A pilot’s difficulty experienced while escaping an aerial firebombing helicopter after it had impacted and sank in a reservoir following an engine failure highlights the potential value of emergency breathing systems, an ATSB investigation highlights. 

Using a 1,400 litre water bucket on a 100 foot long-line, the UH-1H helicopter was collecting water from the Ben Boyd Reservoir to assist bush-fire clean-up operations near Eden on the NSW south coast on 9 January 2020. 

As the helicopter arrived in a 100 ft hover over the water, the pilot heard a grinding noise. In response they jettisoned the long-line and bucket and applied forward cyclic to fly towards land. 

However, the helicopter experienced a complete loss of engine power and immediately descended into the water. On impact, the helicopter’s chin-bubbles fragmented, and the helicopter rolled inverted, filled with water, and sank. 

Unable to open the pilot, co-pilot, or sliding cabin doors, the pilot punched out the right sliding door rear window and escaped the helicopter. The pilot inflated their lifejacket and swam to shore, surviving the accident with minor injuries. 

While the pilot was not carrying, and was not required to carry, an emergency breathing system (EBS), during the escape they found a pocket of air in the cabin, allowing them to take ‘a couple of breaths’. 

“Research into helicopter overwater accident survival consistently reports drowning as the leading cause of fatalities, due to the inability of the occupant to hold their breath long enough to escape,” said ATSB Chief Commissioner Angus Mitchell. 

“In this accident, the pilot found an air pocket in the cabin, which enabled the escape time to extend beyond the initial breath-hold time. While it could not be determined if the pilot would have drowned without the air pocket, it would have increased that likelihood. 

“Although the pilot was able to successfully escape from underwater after finding the air pocket, an emergency breathing system would have reduced the risk of drowning.” 

The pilot had conducted a number of helicopter underwater escape training (HUET) courses, a condition of the operator’s contract with the NSW Rural Fire Service. At interview, the pilot told ATSB investigators he ‘would have been dead without HUET’. 

However, the pilot had not completed the EBS portions of the HUET courses as EBS equipment had not been introduced into their operation.  

A range of EBS options are available on the market, including rebreather, compressed air, and hybrid options. 

“Helicopter underwater escape training – or HUET – provides a learning environment for the essential skills of maintaining orientation, location, and operation of exits,” said Mr Mitchell.  

“However, extended breath-hold may be necessary for problem-solving and physical effort during an underwater escape, such as dealing with snagging hazards, obstructions, or inoperative exits that require an alternative escape route, as in this accident.  

“In these scenarios an EBS can afford the pilot sufficient time to perform the escape actions without an air pocket and therefore reduce the risk of drowning.” 

Following the accident, the pilot acquired a compressed air EBS and intends to conduct the EBS elements of future HUET courses. 

“The operator reported they have started investigating how to implement EBS company-wide, and how to attach the units to their pilots without limiting their movement when conducting long-line operations,” Mr Mitchell said. 

Following a teardown inspection by the manufacturer, the engine failure was determined to have resulted from inadequate lubrication to two main bearings in the front section of the engine, leading to their failure. 

This resulted in contact between the power and compressor shafts, disconnection of rotational drive to the fuel pump and fuel control, and subsequent fuel starvation. 

However, the exact cause of the restriction of oil flow to the main bearings in the front section of the engine was not able to be established. 

Read the report: Engine failure and collision with water involving Garlick Helicopters UH-1H, VH-ONZ, Ben Boyd Reservoir, New South Wales, on 9 January 2020