Papua New Guinea continues to strengthen aviation safety with 12 Papua New Guineans completing training to international standards in air accident reporting.

Papua New Guinea continues to strengthen aviation safety with 12 Papua New Guineans completing training to international standards in air accident reporting.

The training course, jointly run by the PNG Accident Investigation Commission (AIC) and the ATSB, covered the preparation of aviation accident and serious incident reports that meet international standards. The ATSB has been working closely with the PNG AIC to conduct a series of training courses for PNG citizens working in the aviation industry.

The Australian Government shares a partnership goal with PNG of improving aviation services to comply with international safety and security services. The 12 PNG aviation professionals from the public sector and from private aviation operators undertook a five-day course in air accident reporting that began on 10 February at the Air Nuigini Training Centre at Jackson’s Airport, Port Moresby.

Through the PNG Australia Transport Sector Support Program, Australia assists PNG to improve aviation through a diverse range of initiatives.

Conducted by a former ATSB Director, Alan Stray, the course explained International Civil Aviation Organization (ICAO) requirements for accident and serious incident reporting. Through a series of practical examples, participants built their knowledge and skills to prepare accident and incident reports that meet international standards and support improvements in aviation safety in PNG.

The participants, including three women, worked hard and saw the challenging course as a boost to their career prospects. Ms Bessie Andrew of PNG Air Services said, ‘I was so pleased to see other women participants. Accident report writing requires attention to detail and well-developed analytical skills. I feel that this is a great career opportunity for women in PNG.

The Minister for Civil Aviation, the Hon Mr Davis Stephen recognised the training to ICAO standards and presented certificates in a ceremony on 14 February 2014.

Future training courses will cover Safety at Accident Sites and Aircraft Accident Investigation Fundamentals. 

Through the PNG Australia Transport Sector Support Program, Australia assists PNG to improve aviation through a diverse range of initiatives.

Course participants included public sector and private aviation operators

 Ms Jean Mose, manager quality and safety at Airlines PNG, receives her certificate of completion from Civil Aviation Minister Steven Davies

The ATSB has just released a new aviation bulletin containing 9 investigation reports. The Aviation Short Investigation Bulletin Issue 26 covers short, office-based investigations.

The bulletin covers incidents, serious incidents and accidents involving jet, turboprop and piston aircraft, as well as helicopters.

Short investigations cover incidents and accidents where the associated factors are usually well-understood and do not require more detailed investigations. Nonetheless, each investigation has the potential to produce important Safety Messages for pilots, operators and others in the aviation industry. The investigations also help the ATSB identify statistics and trends in air safety.

Issue 26 of the Bulletin features 9 safety investigations:

• Loss of separation assurance between an Airbus A320, VH-VNQ and Boeing 737, VH-VZB
• Incorrect configuration involving Airbus A320, VH-FNP
• Flight planning related event involving an Airbus A330, VH-QPD
• Turbulence event involving a Boeing 767, VH-OGU
• Fuel related event involving a Fairchild SA227, VH-UUO
• Electrical system event involving a Cirrus SR22T, VH-LBQ
• Aircraft proximity event between a Piper PA-44, VH-CZH and a Mooney M20, VH-DJU
• Loss of control involving a Eurocopter EC-120B, VH-VMT
• Aircraft proximity event between a Bell 206, VH-WCS and a PZL Bielsko 51, VH-XOP

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 26

Rail operators are being reminded of the need to report Category A rail occurrences to the Australian Transport Safety Bureau (ATSB) following a number of incidents that have not been reported as required.

Recent reforms to national rail safety legislation have resulted in changes to the way rail occurrences need to be reported in some states and territories. By law, rail transport operators in South Australia, Northern Territory, Tasmania and New South Wales must now verbally report Category A incidents to the ATSB.

A review of reports received by the ATSB, and the Office of the National Rail Safety Regulator (ONRSR) has shown inconsistencies in reporting patterns. In particular:

• some Category A notifiable occurrences are being reported in written form to the ONRSR only with no verbal report to the ATSB
• some Category A notifiable occurrences have been incorrectly classified by operators as Category B and only reported to the ONRSR.

The ATSB and ONRSR remind all operators in these states and the Northern Territory of their responsibilities under the law and that failing to report category A occurrences to the ATSB may incur a penalty. 

All Rail Safety National Law (RNSL) occurrences resulting in serious injury are classified 
Category A 
and only those accidents that result in hospital admission should be reported.

The ONRSR also reminds operators that under the rail national safety law, a running line derailment is a Category A occurrence. (A number of such occurrences have not been reported to the ATSB.)

All Rail Safety National Law (RNSL) occurrences resulting in serious injury are classified Category A and only those accidents that result in hospital admission should be reported (against this category).

The ATSB and ONRSR have released a fact sheet to help operators better understand their reporting responsibilities.

• Fact sheet: Reporting Cat A rail occurrences to the ATSB

A wheels-up landing of a Beech 95-B55 is an important reminder that, when faced with an unexpected equipment malfunction, the most important priority should be to fly the aircraft.

On 20 October 2013, the pilot was preparing for a flight from St Helens Airport, Tasmania. He reported that he closed the aircraft door and noted a distinctive click, indicating that the door was secure. He then completed the taxi and pre-take-off checks and noted that everything was operating normally.

The pilot commenced the take-off and as the aircraft became airborne at about 60 ft above ground level, the door opened. Documents blew out of the door and around the cockpit. The pilot continued the climb to 1,000 ft in preparation to return for landing. He could not recall retracting the landing gear after take-off.

The ATSB has identified 325 occurrences between 1997 and 2004 that involved distractions.

When on the downwind leg of the circuit, the pilot tried to close the door but could not reach it. On turning onto base leg the pilot selected 10 degrees flap and continued the approach. On final, he selected full flap and reduced the throttle setting to idle for landing. As he touched down, the pilot realised the landing gear was retracted. The aircraft slid along the runway and came to rest 600 m from the runway end. It was substantially damaged. The pilot recalled hearing a horn activate during the landing but was unable to distinguish whether it was a stall warning or the landing gear warning horn.  

The pilot commented that he normally lowered the landing gear on the downwind leg [or on downwind], but omitted to do so on this occasion. He had never heard the landing gear warning before and was not aware what it sounded like. He normally used memorised checks but resolved that, in future, he would use written checks. An engineering inspection found the door appeared to be twisted and not sitting flush, though it was lockable. About 9 years earlier the door had opened on take-off but had since been repaired by engineers.

The ATSB has identified 325 occurrences between 1997 and 2004 that involved distractions. The source of distraction for the majority (where a source could be established) related to equipment problems, including five involving doors opening. The Flight Safety Foundation recommends that, after a distraction source has been identified, the next priority should be to re-establish situational awareness by conducting the following:

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

The report has links to publications containing further information on pilot distraction.

Read the final report: Wheels-up landing involving Beech 95-B55, VH-TLP, at St. Helens Airport, Tasmania, on 20 October 2013

The ATSB has just released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 25 covers short, office-based investigations.

The bulletin covers incidents, serious incidents and accidents involving turboprop aircraft, piston aircraft and helicopters. In some of the occurrences, people suffered minor injuries while some of the aircraft were substantially damaged.

Short investigations cover incidents and accidents where the associated factors are usually well-understood and do not require more detailed investigations. Nonetheless, each investigation has the potential to produce important Safety Messages for pilots, operators and others in the aviation industry. The investigations also help the ATSB identify statistics and trends in air safety.

The incidents covered in the report include:

• Runway event involving a Beech 1900C, VH-­VNV
• Runway incursion between a Fairchild SA227, VH-­UZP and a Bell 47G, VH-­UTF
• Pilot incapacitation event involving a Cessna 210, VH-JMG
• Aircraft proximity event between a Cessna 172, VH-­NUU and a Beech F33A, VH­-ZBZ
• Wheels-up landing involving a Beech 95­B55, VH­-TLP
• Runway undershoot involving a Cessna 404, VH­-HAZ
• Loss of control involving a Cessna 172, VH-IGS
• Mid-air collision involving a Cessna 152, VH-­TNV and a Jabiru J160, 19­4430
• /publications/investigation_reports/2013/aair/ao-2013-203
• Total power loss involving a Robinson R22, VH-­STK

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 25

The ATSB today released a report warning pilots on the dangers of flying visually at night following a number of fatal accidents that occurred in dark-night conditions.

The report comes shortly after the release of the ATSB’s investigation into the fatal helicopter crash at Lake Eyre where the pilot likely became spatially disoriented during a visual flight at night.

ATSB Chief Commissioner, Mr Martin Dolan, said accidents involving visual flight at night are becoming an increasing safety concern in Australian aviation.

Even when undertaken by appropriately qualified pilots, night flight clearly presents an added level of complexity.

“Over the past 20 years, the ATSB has investigated 36 accidents as a result of visual flight at night. Of these accidents, 27 had fatal outcomes which tragically led to 58 fatalities,” Mr Dolan said.

“Even when undertaken by appropriately qualified pilots, night flight clearly presents an added level of complexity.

“But accidents of this nature are avoidable and can be managed by pilots maintaining their proficiency, knowing their own personal limitations and only flying in environments that do not exceed their capabilities.”

The report, which features case studies on several night-flight accidents, helps pilots better understand and manage the dangers of flying at night.

Visual flight at night accidents: What you can’t see can still hurt you

The Aviation Short Investigation Bulletin Issue 24 contains 15 investigation reports.

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 24 of the Bulletin features 15 safety investigations:

Jet aircraft

• Runway event involving a Fokker F28, VH-JFB
• Ground proximity event between a Boeing 737, VH-VZA and a security vehicle

Turboprop aircraft

• Wheels up landing involving a Cessna 441, VH-SMO
• Airspace related event involving a Saab 340B, VH-ZLJ and parachutists
• Wirestrike involving an Air Tractor AT 502, VH-CJY

Piston aircraft

• Landing on a closed runway involving a Cessna 404, VH-HVR
• Fuel starvation event involving a Beech BE58, VH-ECL
• Loss of control involving a Piper PA 28R-200, VH-MMU
• Engine fire involving a Beech A36, VH-FFY
• Runway incursion involving a De Havilland DH 82, VH-BJE and a Piper PA 34, VH-SEN
• Runway incursion between a Cessna 206, VH -LHX and a Cessna 210, VH-HGZ
• Total power loss involving a Piper PA 28 140, VH-RVJ

Helicopters

• Partial power loss involving a Bell 47G, VH-RTO
• Aircraft proximity event between a Cessna 172, VH-RQZ and an Agusta AW139, VH-ESZ
• Aircraft configuration event involving a Robinson R22, VH-ONT

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 24

The fatal accident involving a Piper PA-28-180 Cherokee highlights the risks of flying at night under the visual flight rules (VFR).

On 15 August 2011, the pilot was conducting a private flight transporting two passengers from Essendon to Nhill in Victoria under the VFR. The flight was arranged by the Angel Flight charity to return the passengers to their home after medical treatment in Melbourne.

Global Positioning System data recovered from the aircraft indicated that when about 52 km from Nhill, the aircraft conducted a series of manoeuvres followed by a descending right turn. The aircraft subsequently impacted the ground at 1820 Eastern Standard Time, fatally injuring the pilot and one of the passengers. The second passenger later died in hospital as a result of complications from the injuries sustained in the accident.

A VFR flight in dark night conditions should only be conducted by pilots with high instrument flying proficiency as there is a significant risk of losing control if attempting to fly visually in such conditions.

The ATSB found that the pilot had landed at Bendigo and accessed a weather forecast before continuing towards Nhill. After recommencing the flight, the pilot probably encountered reduced visibility conditions approaching Nhill due to low cloud, rain and diminishing daylight. That likely led to disorientation, loss of control and impact with terrain. One of the passengers was probably not wearing a seatbelt at the time.

The ATSB also established that flights are permitted under the visual flight rules at night in conditions where there are no external visual cues for pilots. In addition, pilots conducting such operations are not required to maintain or periodically demonstrate their ability to maintain aircraft control with reference solely to flight instruments.

As a result of previous ATSB investigations the Civil Aviation Safety Authority (CASA) has drafted new legislation, effective 4 December 2013, requiring a biennial review for night VFR‑rated pilots. CASA has also indicated that it will clarify what is meant by the term ‘visibility’ in dark night conditions, provide enhanced guidance on night VFR planning and other aspects of night VFR operations.

This tragic accident serves as a reminder for operators and pilots considering night VFR flights to assess the likelihood of dark night conditions by reviewing weather conditions, celestial illumination and available terrain lighting. A VFR flight in dark night conditions should only be conducted by pilots with high instrument flying proficiency as there is a significant risk of losing control if attempting to fly visually in such conditions.

The ATSB will soon release an educational booklet in its Avoidable Accidents series related to visual flight at night. The booklet will highlight risks associated with night VFR flight and discuss strategies for their management.

Read the final report: VFR flight into dark night conditions and loss of control involving Piper PA-28-180, VH-POJ, 31 km north of Horsham Airport, Victoria, on 15 August 2011

An ATSB research report into stall warning events has given new insights into the way in which Australian pilots respond when flying at the margins of safe flight.

An ATSB research report into stall warning events has given new insights into the way in which Australian pilots respond when flying at the margins of safe flight.

Stall warnings indicate to a flight crew that their aircraft will approach a stall if action is not taken to reduce the aircraft’s angle of attack.

Transport Safety Investigation Regulations require that, if a pilot receives a stall warning, they must report it to the ATSB. There were about 250 stall warnings reported to the ATSB in high-capacity air transport in Australia in the five years between 2008 and 2012.

Stall warnings were found to occur in all flight phases and a range of aircraft configurations...

About 75 per cent of the stall warnings reported to the ATSB were genuine warnings of an approaching stall. In only a minority of cases were system problems reported that resulted in false or spurious stall warnings.

Most stall warnings were associated with stick shaker activations, were momentary in duration, and were associated with thunderstorms, clear air turbulence, sudden wind gusts, or windshear, in both visual and instrument meteorological conditions. As a rate per hours flown, stall warnings were more common in Dash 8, Boeing 767, Boeing 717 and Fokker F100 aircraft, although for the F100, almost all reports were for the aircraft’s stall warning systems activating spuriously. Stall warnings were found to occur in all flight phases and a range of aircraft configurations, not exclusively those related to slow speed, high pitch attitude flight, or flight in poor meteorological conditions.

Read the ATSB research report AR-2012-172

The ATSB has just released a new aviation bulletin containing 13 investigation reports. The Aviation Short Investigation Bulletin Issue 23 covers short, office-based investigations.

The bulletin covers incidents, serious incidents and accidents involving jet aircraft, turboprop aircraft, piston aircraft and helicopters. In some of the occurrences, people suffered minor injuries while some of the aircraft were substantially damaged.

Short investigations cover incidents and accidents where the associated factors are usually well-understood and do not require more detailed investigations. Nonetheless, each investigation has the potential to produce important Safety Messages for pilots, operators and others in the aviation industry. The investigations also help the ATSB identify statistics and trends in air safety.

The incidents covered in the report include:

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

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 23