The ATSB recommends owners of CH-7B series helicopters ensure the integrity of the stabiliser before flying.

• The ATSB recommends owners of CH-7B series helicopters ensure the integrity of the stabiliser before flying.

The ATSB is investigating a second fatal accident involving in‑flight separation of the stabiliser, and subsequent loss of control, involving Cicaré CH-7B helicopters.

Preliminary technical examination at the ATSB’s facilities in Canberra, indicates that in both instances the stabiliser failed due to cracking associated with metal fatigue. In the most recent accident, the crack propagated in a circumferential manner through approximately 75 per cent of the welded structure prior to failure.

While the ATSB is working to establish the factors leading to the two failures, owners are advised to exercise extreme caution in the operation of their helicopters.

The examination showed cracking in the stabiliser attachment outboard of the tail boom, coincident with the welded intersection of the conical and tubular sections of the attachment. The location of the cracking in the attachment cannot be easily inspected as they are obscured by the upper and lower vertical stabiliser fairings.

Stabiliser attachment failure location

The cracking is unlikely to be easily visible during inspection. However, black dust in the vicinity of the attachment bracket, and working rivets are indicative of increasing stabiliser movement as the crack develops.

The ATSB is working to establish the origin of the failure. However, initial indications are that the fatigue cracking occurred after as little as 100 hours of operation and may be associated with aerial stock mustering. Additionally, in the first accident, operation of the helicopter with a high level of vibration may have been a factor.

CH‑7Bt tail section showing the location of fatigue fracture on the stabiliser attachment

Fractured stabiliser attachment bracket with black dust outlined in white (in two places)

Typical indication of ‘working’ rivets (photograph not of a CH-7B helicopter)

The ATSB recommends that owners of CH-7B series helicopters ensure the integrity of the stabiliser prior to further operation and on an ongoing basis. While the ATSB is working to establish the factors leading to the two failures, owners are advised to exercise extreme caution in the operation of their helicopters.

Cicaré has advised that if any doubt arises concerning the inspection or maintenance of any part, piece or component, their technical department should be immediately consulted.

In addition, owners may wish to discuss any concerns with an appropriately‑licenced aircraft maintenance engineer, the Sport Aircraft Association of Australia or with the Civil Aviation Safety Authority before further flight.

If you find any cracks in the stabiliser attachment, please call us on 1800 020 616 or email ATSBinfo@atsb.gov.au.

Related investigations:

• AO-2014-086 - In-flight break-up involving Cicaré CH-7B, VH-SWQ, 43 km north-west of Barcaldine Airport, Queensland, on 12 May 2014
• AO-2015-089 - In-flight break-up involving Cicaré S.A. CH-7BT helicopter, VH-JEW, near Roy Hill Station, Western Australia, on 28 July 2015

Carrying an e-cigarette in your luggage can pose a safety hazard to flights.

A recent incident in the United States demonstrates the potential risk after a passenger found her e-cigarette was smouldering and smoking in her handbag after she got off her flight. Walking through the terminal she realised something was wrong and hurried outside to dump her bag. It had generated enough heat to melt several items in her handbag.

The passenger said that the safety switch on the e-cigarette was off. If the timing was even a little different, it could have resulted in a fire on board the aircraft during flight.

Anyone involved in flight operations, and even passengers, can report a safety concern.

Airline passengers are reminded that e-cigarettes are considered to be personal electronic devices. They must only be carried on aircraft on your person or in your carry-on luggage. Like other lithium battery devices, there is a risk of their catching fire. The ATSB has been notified of similar incidents of smouldering items — including mobile phones, tablets, and an air purifier — carried on board by passengers in recent years.

This incident was reported by a cabin crew member to the United States’ Aviation Safety Reporting Scheme (ASRS), a confidential reporting scheme run by NASA. In Australia, the ATSB runs a similar confidential safety reporting scheme called REPCON. Anyone involved in flight operations, and even passengers, can report a safety concern.

If you have any information which you consider may affect aviation safety please do not keep it to yourself. You can contact the REPCON office on 1800 020 505 or submit a report online.

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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.

• 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.

The owner and pilot of a Piper Saratoga had held a private pilot licence with a night VFR rating for many years. The pilot was not current in night flying. On 30 March 2011, he had flown from Moree to Brewarrina with five passengers, intending to return that evening.

On the return flight, the pilot made a number of detours to allow the passengers to see particular landmarks, and by the time the aircraft returned to Moree, it was dark.

Two legs of the circuit at Moree Airport were flown toward Moree town centre, which provided enough ground lighting to allow the pilot to control the aircraft. The final approach was over a caravan park and highway. However, there was relatively limited ground lighting along the aircraft’s intended flight path in the last 500 m before the runway, except for the runway lighting ahead.

The aircraft was very low on the final leg of the circuit. The left wing impacted the top of a tree in the caravan park, 700 m north of the runway. The aircraft rolled inverted and impacted the ground about 150 m later. Two passengers survived the
accident.

Lessons learnt

Even if there is ground lighting, terrain clearance will be assured by continually matching the aircraft’s position in the circuit and on the approach against the expected altitude. This check allows a pilot to correct the height early if needed. Night currency enables a pilot to maintain the necessary skills and judgement to safely fly at night, such as an earlier detection and correction of an undershoot or shallow approach path

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.

Read more about: Visual flight at night accidents

Read the final report: Controlled flight into terrain involving Piper Saratoga PA 32R 301T, VH-LKI, Moree Airport, New South Wales, on 30 March 2011

Learn more about Flying with reduced visual cues

• Pilots must operate within personal limits when flying in darker environments. Night ratings and instrument ratings entitle pilots to fly at night, but the skills needed to fly over a city at night are very different from the skills necessary to fly when there is nothing to be seen.

Ten minutes after the end of daylight on 27 July 2011, the pilot of a Robinson R22 helicopter took off from Big Rock Dam stockyards on Brooking Springs station to fly back to the homestead, a flight that would normally take 30–40 minutes.

The route normally used flew over an area devoid of ground lighting, then over a limestone ridge to a plain, from which the lights of Fitzroy Crossing would come into view. At some point from there, the flight would be diverted to the Brooking Springs homestead.

The pilot took off at about sunset, and initially flew at normal cruising speed, but gradually slowed until the helicopter orbited over a dirt track before heading towards Fitzroy Crossing. Thirty minutes after the end of daylight, the helicopter flew very low and very slow, possibly flying by reference to terrain visible through illumination from the helicopter’s landing lights. Ten minutes later, when it would have been fully dark, the helicopter climbed from about 100 ft to 600 ft above ground level, and turned towards the homestead. During the turn, the helicopter increased groundspeed from 5 to 95 knots, attained a rate of descent, and collided with the terrain. The pilot sustained fatal injuries during the accident.

The pilot had never received night flying training or obtained a Night Visual Flight Rules rating. The aircraft was equipped with suitable lighting for night flight, but it did not have the necessary instrumentation or other equipment necessary to enable a pilot to fly safely by night.

In this accident it is likely that the pilot lost control of the helicopter due to spatial disorientation from insufficient visual reference to keep the helicopter the right way up.

Lessons learnt

Many things must be in place for a safe night flight to happen. Do not fly at night unless you are trained and qualified to do so and you know all the requirements and are able to apply them.

A flight that cannot be completed by nightfall should not even be started unless all the necessary requirements are in place to allow a safe night flight and landing.

In very dark conditions such as rural areas, the skills needed to fly an aircraft at night are vastly different to day VFR flight, and may even exceed the capabilities of some pilots trained in night VFR operations.

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.

Read more about: Visual flight at night accidents

Read the final report: Collision with terrain involving Robinson R22 helicopter, VH-YOL, 14 km north-west of Fitzroy Crossing, Western Australia, on 27 July 2011

Learn more about: Flying with reduced visual cues

The US Securities Exchange Commission states that, ‘Past performance does not guarantee future results’, but in aviation safety, past performance can point to future accidents.

Tracking past performance is called trend analysis, and one way that the Australian Transport Safety Bureau helps to keep transport safe is by analysing trends in aviation safety occurrences and identifying actions that will reverse safety concerns.

Each six months the ATSB releases a report called Emerging trends in Australian aviation safety in which ATSB shares issues of interest with industry and other government agencies. People and organisations can then take safety action to prevent identified issues from resulting in accidents.

The ATSB monitors more than 100 different events for each three operation type and uses six-monthly reports to highlight emerging trends. In the second half of 2014 there were four increasing trends highlighted:

• navigation aid failures affecting high-capacity airline operations
• turbulence and windshear affecting high-capacity airline operations
• aircraft to aircraft communications affecting low-capacity airline and charter operations, and
• ground proximity alerts affecting high-capacity airline operations.

While the graphs show each of these emerging trends to be rising, the occurrence rate is exceptionally small. For example, if we look at how often windshear and turbulence events affect larger airline aircraft operations, the rate is 0.08 per cent of flights. In other words, you would have to fly 1250 times before experiencing one of these occurrences. These sort of occurrences follow seasonal climatic conditions with peaks in the October to December quarter each year. Passengers can be assured that the ATSB will continue monitoring this trend.

When aviation safety incidents and accidents happen, they are reported to the ATSB. We investigate the most serious of these, but most reports are simply used to help build a picture of how prevalent certain types of occurrences are in different types of aviation operations.

The ATSB uses this data to look for emerging safety trends. By monitoring trends, issues of concern can be communicated and action taken to prevent accidents.

Read the ATSB report: Emerging trends in Australian aviation safety: July to December 2014

The Chief Commissioner of the Australian Transport Safety Bureau, Mr Martin Dolan has welcomed the re-appointment of Mr Noel Hart as a Commissioner with the ATSB.

Deputy Prime Minister and Minister for Infrastructure and Regional Development Warren Truss announced the two-year extension of Mr Hart's term today, effective from 1 July 2015. Mr Hart was first appointed as a Commissioner in July 2009.

Mr Dolan said, ‘Mr Hart brings to the Commission a lifetime of experience in maritime industry experience as a qualified and experienced Master Mariner with an MBA.

‘I look forward to continuing the Commission’s important work with Noel whose maritime knowledge complements the aviation and rail experience of the other Commissioners.

Read Deputy Prime Minister Truss’ statement.

More information on ATSB's commissioners can be found here.

Recent news reports about the search for MH370 have included highly inaccurate assertions about the search and how it is being conducted.

The ATSB strongly refutes assertions that Fugro Survey Pty Ltd was not the best choice to undertake the underwater search or that the search methods are ineffective. The search is being carried out to the highest standards of effectiveness and quality.

“These attacks are unfounded and unfair”, said Chief Commissioner Martin Dolan. “The search for MH370 represents thousands of hours of work by hundreds of people who are dedicated, expert and professional. They are fully committed to finding the aircraft.

“The opportunity to tender services for the search for MH370 was open to the international underwater search industry. We received a number of tenders which encompassed a range of different capabilities and methods. A comprehensive and exhaustive evaluation process was conducted in line with strict Australian Government procurement and probity rules.

“I am very conscious that we must use taxpayers’ money responsibly. Fugro’s bid represented the best value for money and demonstrated that they could capably manage the technical aspects of this challenging search operation and deliver the necessary results.”

Fugro has been involved with numerous aircraft and helicopter search and recovery operations since the 1980s. They have been using the Edgetech Deeptow side-scan sonar systems since the mid-90s and have one of the largest commercial AUV fleets in the world for performing commercial surveys in deep water.

Their ability to detect man-made objects on the seafloor in ultra-deep water is evidenced by the recent detection of a previously unknown shipwreck.

“The debris in the shipwreck field was significantly smaller, and therefore harder to detect, than we expect to find with MH370,” Chief Commissioner Dolan said.

“The ATSB has put in place systems of review and expert quality assurance so we can be certain that the quality of search data meets the high standards we have specified,” said Chief Commissioner Dolan. “We selected Fugro on their capacity to meet those standards.”

As part of its quality assurance process, the ATSB has enlisted the expertise of Sherrell Ocean Services founded by Andrew Sherrell, one of the leading sonar search specialists in the world, who has worked on a number of commercial air investigations, including the search and recovery of Air France 447, TWA 800, and Egypt Air 990.

Mr Sherrell has been involved as the Quality Assurance Manager in many elements of the search for MH370, beginning with the tender process and continuing with the planning of the search and review of the gathered sonar data. Mr Sherrell said he is confident that the appropriate technology is being used.

“The equipment was tested thoroughly in ocean trials at a purpose-built test range to ensure the maximum swath width without compromising the detection capability. Fugro’s faster-than-average tow speed enables them to scan significant amounts of sea floor per operational day. As a result, we are seeing substantial coverage with the required level of resolution,” said Mr Sherrell.

“We have a rigorous and thorough quality assurance program that ensures appropriate overlap between adjacent swaths and positioning of each line as well. We are achieving very accurate and consistent results with a new state-of-the-art positioning system that gives us full confidence in the towfish position, even 9km behind the vessel.

“Furthermore, we verify this system by using the accurate bathymetry maps collected during Phase 1 of this search. By matching specific features on the seafloor, we can ensure that the positions being calculated are correct, and we do this for every single line of data collected. We also perform feature matching with the side scan sonar data between adjacent lines to ensure sufficient overlap of data is maintained. This is also done on every line as it is collected, with any deficiencies documented and catalogued.

“In addition, Fugro are using multibeam sonar to supplement the side scan sonar equipment; this covers the traditional “nadir” gap directly below the towfish. The multibeam ensures more complete coverage of the seafloor it passes over. This is optimising our rate of progress, and is a feature that is not available on some older systems that are still in use by other organisations.”

Without this type of system, a much higher percentage of seafloor would need to be covered twice to fill in this missing data. Duplicating coverage of the seafloor not only increases the cost of the search, but also the time required to cover the search area. Using a multibeam sonar in this way is a very efficient technique for covering large areas of seafloor.

“The challenges remain,” Chief Commissioner Dolan said. “The search zone is remote, the weather and sea conditions are difficult, and the search area is vast, but I’ve never had any doubt about the capabilities of Fugro, their commitment to the mission or their professionalism.”

Learn more about The search for MH370

The Australian Transport Safety Bureau has released its latest Bulletin of short investigations covering incidents involving regular passenger transport aircraft, light aircraft and helicopters.

Issue 41 of the Bulletin covers 13 safety investigations and highlights valuable safety lessons for pilots, operators and safety managers.  The Bulletin also highlights important safety messages for the broader aviation community, drawing on earlier ATSB investigations and research.

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 or identified.

Issue 41 of the Bulletin features 13 safety investigations:

Jet aircraft

• Main landing gear wheel failure involving a Boeing 737, ZK-ZQB
• Operational event involving a Boeing 737, VH-VUR

Piston aircraft

• Wheels-up landing involving a Cessna 210, VH-JGA
• Engine failure and forced landing involving Cessna 210, VH-TWD
• Near collision involving a Diamond DA20, VH-YNB and a Mooney M20, VH-SJT
• Runway overrun involving an Aero Commander 500, VH-WZV
• Collision on the ground involving a Piper PA-28, VH-TXH and a Cessna 172, VH-EUU
• Runway excursion involving a Cessna 404, VH-JOR

Helicopters

• Collision with terrain involving a Schweizer 269C-1, VH-FTY
• Collision with terrain involving Robinson R44, VH-YMD
• Loss of control, involving a Robinson R22, VH-YLP
• Collision with terrain involving a Robinson R22, VH-CMK
• Collision with terrain involving a Robinson R22, VH-HUA

Follow this link to: Aviation Short Investigation Bulletin - Issue 41

• Accident highlights the impact a combination of distractions can have on aircraft operations.

On 12 December 2014, the pilot of a Cessna 310 (C-310) aircraft, registered VH-TBE (TBE), was completing a charter flight from Oenpelli to Jabiru, Northern Territory. On board were the pilot, two adults and three children.

TBE was one of several aircraft operating multiple flights between the two communities, and this was the fourth and final flight for the pilot that day. Due to the late arrival of a passenger on one of his earlier runs, the pilot had been delayed throughout the morning.

After departing Oenpelli, he made a left turn, and continued climbing to 2,000 ft for the short flight. An agreed local procedure between operators in this area was that flights from Oenpelli to Jabiru operated at 2,000 ft, and flights in the opposite direction at 1,500 ft.

After a distraction source has been recognised, the next priority is to re-establish situation awareness by conducting the following:
Identify: What was I doing?
Ask: Where was I distracted?
Decide/act: What decision or action do I need to take to get back on track?

The pilot reported that the three children on board were excited and a little disruptive, and he had kept a close watch on their activities. Concurrently, the passenger seated in the front seat coughed incessantly through the headset, which distracted him. Once he had the aircraft stable, he reached over and unplugged the passenger’s headset.

After the completion of the top of descent (TOPD) checks, he manoeuvred to join a late downwind for a right circuit onto runway 27 at Jabiru. He commenced the pre-landing checks and reported verbalising “undercarriage down”, but made a decision to leave this particular action until later on final approach. He elected to keep the aircraft speed slightly higher than normal; and as per the company procedures, kept a stable power setting and profile and only made small adjustments when needed at around 300 ft. He was also mindful of a Cessna 210 aircraft close behind TBE.

He then focussed on the passengers, especially the children, and made sure that they all had their seatbelts correctly fastened prior to landing. The children were still highly excited. He normally completed the remaining memory-recall PUFF check on final approach, but on this occasion he did not.

The pilot flared the aircraft in preparation for landing. He became aware that the undercarriage remained retracted when TBE touched down on the runway centreline and he heard the propellers contacting the ground.

Mindful there was an aircraft in the circuit behind him, he used the remaining rudder effectiveness to move the aircraft slightly to the left of the runway. When the aircraft came to a stop, he checked on the welfare of his passengers and opened the door for them to exit, directing them to assemble in a safe area. After completing shutting down, he also exited the aircraft. There were no injuries to either the pilot or passengers; however, the aircraft was substantially damaged.

Safety message

This incident highlights the impact a combination of distractions can have on aircraft operations.

Research conducted by the ATSB found that distractions were a normal part of everyday flying, and generally pilots respond to them fairly and efficiently. It also revealed that 13 per cent of accidents and incidents associated with pilot distraction between January 1997 and September 2004 occurred during the approach phase of flight.

The Flight Safety Foundation suggests that after a distraction source has been recognised, the next priority is to re-establish situation awareness by conducting the following:

• Identify: What was I doing?
• Ask: Where was I distracted?
• Decide/act: What decision or action do I need to take to get back on track?

Read the final report: Wheels-up landing involving a Cessna 310, VH-TBE, Jabiru Airport, Northern Territory, on 12 December 2014

Further reading is available at:

• Dangerous Distraction: An examination of accidents and incidents involving pilot distraction in Australia between 1997 and 2004.
• Flight Safety Foundation Approach-and-landing Briefing Note 2.4 – Interruptions/Distractions(Opens in a new tab/window)