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 As he touched down, the pilot realised the landing gear was retracted.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

A helicopter pilot’s prompt response to a rattling noise in a Robinson R22 helicopter avoided a potentially serious accident.

A helicopter pilot’s prompt response to a rattling noise in a Robinson R22 helicopter avoided a potentially serious accident.

On 12 October 2011, the pilot was performing aerial work near Saxby Downs, Queensland when he heard the rattling noise. He opened the clutch actuator circuit breaker and, at the same time, noticed a burning rubber smell. He immediately made a precautionary landing and shut down the helicopter.

The ATSB’s investigation into this incident, traced the problem to the clutch assembly where a group of locking nuts had cracked and fractured. This cracking had stemmed from the likely embrittling effect of residual hydrogen generated during the cadmium electroplating process applied during manufacture. The nut failures led to a series of mating part failures and a breakdown of the clutch assembly, producing the symptoms experienced by the pilot, which led to the landing.

The prompt actions of the pilot who followed emergency procedure requirements by landing immediately avoided a potentially serious accident.

At the time of this occurrence the brittle failure of MS21042L-series nuts was an emerging airworthiness issue and several safety actions had already been implemented. Two months before this occurrence, the helicopter manufacturer issued service letters alerting owners and maintenance personnel to the potential for cracking and requiring the replacement of any cracked nuts on inspection.

On the same day as this occurrence, the Civil Aviation Safety Authority (CASA) issued an Airworthiness Bulletin alerting pilots and maintenance personnel of the need to closely monitor the condition of high-strength steel hardware (such as these nuts) with a view to identifying any failures that may have resulted from hydrogen-induced cracking.     

In April 2012, the manufacturer of the nuts issued a Technical Quality Notice Bulletin addressing, in detail, many procedural improvements that were being introduced to reduce the potential for hydrogen-related failure of this nut type.

The prompt actions of the pilot who followed emergency procedure requirements by landing immediately avoided a potentially serious accident. This occurrence highlights the importance of being vigilant when conducting pre-flight and maintenance inspections. It also reveals the importance of pilots and maintenance personnel remaining attentive to the release of new information about new or emerging airworthiness issues that may affect their operations.

Read the final report: Embrittled nut and related failures Robinson R22 Beta, VH-JNP, 22 km north of Saxby Downs, Queensland, on 12 October 2011

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

Research report focusses on occurrences over the last ten years, identifying improvements and problems.

The ATSB’s latest research report focusses on aviation safety occurrences over the last ten years, identifying improvements and problems.

Every year, thousands of safety occurrences involving Australian-registered and foreign aircraft are reported to the ATSB by individuals and organisations in Australia’s aviation industry, and by the public. The vast majority are minor, but there are serious incidents and accidents. Each notification is retained in the ATSB’s databases, building up a detailed picture of Australian aviation.

The report describes what accidents and incidents have happened, how often they are happening, and what we can learn from them.

The new ATSB report, Aviation Occurrence Statistics 2003 to 2012, gives that information back to pilots, operators, regulators, and other aviation industry participants. The report describes what accidents and incidents have happened, how often they are happening, and what we can learn from them.

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. A new addition to this report is data on 274 occurrences involving recreational (non–VH) aircraft safety.

These statistics provide an important 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.

Read the ATSB research report, AR-2013-067

A research report released today by the ATSB reveals that the vast majority of loss of aircraft separation occurrences in Australia present little or no risk of collision, but more can be done to improve safety.

A research report released today by the ATSB reveals that the vast majority of loss of aircraft separation occurrences in Australia present little or no risk of collision, but more can be done to improve safety. (A loss of separation occurs when two aircraft under air traffic control come closer than a minimum separation distance.)

The report shows that Australia has one of the lowest loss-of-separation occurrence rates, attributable to civilian air traffic control, in the world. A loss of separation (LOS) between aircraft under air traffic control happens on average once every 3 days. In almost 90 per cent of LOS occurrences there was no or a low risk of aircraft colliding. Australia has about six LOS occurrences each year that represent an elevated safety risk. However, a LOS does not normally indicate that there was a near-collision between aircraft. There have been no midair collisions in Australia involving aircraft being provided with a separation service by air traffic control.

The report also reveals that half of all LOS occurrences are attributable to air traffic controller actions, while the other half result from pilot actions. The ATSB considers that more can be done to learn from LOS occurrences attributable to pilot actions in civil airspace.

The number of LOS occurrences under military control was found to be relatively high and most are the result of controller actions. The report finds that current regulatory arrangements do not enable the Civil Aviation Safety Authority (CASA) to give the same level of safety assurance for civilian aircraft under military control as it does for aircraft under civilian control. The ATSB has issued safety recommendations to the Department of Defence and CASA to address the safety issues identified in the report.

The release of this report coincides with the release of two other ATSB investigation reports into separate incidents (one near Ceduna, SA and the other about 900 km northwest of Karratha, WA) that involved losses of separation between passenger aircraft under air traffic control. As part of the Karratha investigation, the ATSB issued two safety recommendations to Airservices Australia. These recommendations were issued in response to the limited formal guidance available on the monitoring of newly endorsed controllers and the use of clearances that allow aircraft to operate anywhere between two flight levels, rather than at a single level.

All three reports are available on the ATSB website.

• AR-2012-034   Breakdown of separation between aircraft in Australia: 2008 to 2011
• AO-2011-144  Breakdown of separation - Boeing 737, VH-VXM and Boeing 737, VH-VUV, near Ceduna Airport, SA, 8 November 2011
• AO-2012-012  Loss of separation between Airbus A320, 9V-TAZ and Airbus A340, A6-EHH near TANEM, 907 km NW of Karratha, WA, 18 January 2012