A helicopter accident at Horn Island has shown the challenges that can accompany night operations, as well as the speed with which things can suddenly go wrong.

A helicopter accident at Horn Island has shown the challenges that can accompany night operations, as well as the speed with which things can suddenly go wrong.

The accident occurred on 13 June 2013. At about 7.24 pm, a Bell 412 helicopter departed Horn Island, Queensland on a training flight to Prince of Wales Island in the Torres Strait. It was a dark night with a small crescent moon and no discernible horizon. On board was the pilot flying (PF) who was under instruction, a training pilot, and a crewman. The purpose of the flight was to conduct several practice approaches using a searchlight to illuminate the ground. Each approach would be conducted to about treetop height, from where a go-around was to be commenced. The manoeuvres were demanding, and would require a high degree of precise flying.

Earlier in the day, the crew had positioned a strobe light at the target location, so that it would be visible on the night flight.

Having returned to the location for the training, they set about conducting their first practice approach, flying towards the strobe as they descended from 2,000 ft. 

At 1,000 ft above the ground, the crewman opened and secured the cabin door. Due to the wind rush he did not look outside continuously until reaching about 400 ft, after which time he was to provide instructions to guide the pilot to the landing area once the PF lost sight of the strobe beneath the helicopter.

Due to the wind rush he did not look outside continuously until reaching about 400 ft, after which time he was to provide instructions to guide the pilot to the landing area once the PF lost sight of the strobe beneath the helicopter.

As they drew nearer to the strobe, the training pilot looked out of the cockpit to confirm all was well to continue a visual approach. When he looked back, he saw that they were descending at a high rate and that the airspeed was below 35 knots. He called ‘Go around’. As there was no immediate response, he repeated the call to go around.

Although the PF commenced a go-around and responded ‘Going around,’ the crewman observed that the helicopter was still descending rapidly and approaching the trees. He called ‘Climb, climb, climb.’ Despite the actions of the pilot, the descent continued and he again called ‘We are going backwards, trees, climb, climb, climb!’

The training pilot took the controls to assist with the go-around and then became aware of the trees in his peripheral vision. As the helicopter descended into the trees, he called ‘Brace, brace, brace!’

The helicopter hit the ground heavily and remained upright.

The crew were uninjured, but the helicopter was substantially damaged. They shut down the helicopter and discharged flares from the accident site, to assist rescuers in locating them.

The helicopter operator hypothesised that the high rate of descent and decreasing airspeed resulted in a vortex ring state—an aerodynamic condition in which the helicopter’s own downwash recirculates, with a potential loss of control.

As a result of this accident, the helicopter operator is conducting a management review into a Flight Safety Instruction that will prohibit unaided (non-night vision goggles) remote landings at night.

Read the final report: Collision with terrain involving Bell 412, VH-EMZ, 12 km west-south-west of Horn Island Airport, Queensland, on 13 June 2013, which includes links to useful research and articles about night operations.

The ATSB has just released a new aviation bulletin containing 11 investigation reports. The Aviation Short Investigation Bulletin Issue 22 covers short, office-based investigations. 

The bulletin covers incidents, serious incidents and accidents involving turboprop aircraft, piston aircraft and helicopters. No one was injured in any of the incidents; however, some of the aircraft suffered substantial damage.

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:

• Left main landing gear collapse involving a Raytheon B200, VH-ZCO
• Aircraft proximity event between a Fairchild SA227, VH-HVH and an Aerospatiale AS350, VH-JRJ
• Aircraft proximity event between two Cessna 172s, VH-EOE and VH-LWX
• Aircraft proximity event between a Piper PA-28, VH-TXH and a Cessna 172S, VH-EWX
• Operation below minimum safe altitude involving Aero Commander, VH-TQA
• TCAS warning between a Cessna 310R, VH-AEY and a Fokker F28-100, VH-FKJ
• Runway incursion involving a Piper PA-31, VH-KLS and a vehicle
• Total power loss involving a Mooney M20J, VH-NFP
• Aircraft proximity event between a Cessna 172, VH-WYG and a Cessna 185, VH-OZX
• Collision with terrain involving a Bell 412, VH-EMZ
• Aircraft proximity event between a Janus glider, VH-IZI and a McDonnell Douglas 500N, VH-KXS

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 22

• The video can be found on the ATSB’s YouTube channel, ATSBinfo(Opens in a new tab/window)

A new ATSB video shows how easily unexpected events can dramatically increase confusion among flight crew while landing the aircraft.

The incident featured in the video is just one in an increasing number of cases where pilots mishandle or mismanage their aircraft when something unexpected happens during the approach to land phase.

ATSB Chief Commissioner, Martin Dolan, said flight crew and operators should be aware of the growing number of safety occurrences, worldwide, during the landing phase.

“When compared to other phases of flight, the approach and landing has a substantially increased workload and risk,” Mr Dolan said. 

“The ATSB has investigated several incidents that occurred during the approach to land and found that poor communication and lack of role clarification were worryingly common.

“As well as showing how easily flight crew can become confused during an unexpected event, the video emphasises the importance of conducting a go-around to ensure a safe outcome.”

The ATSB’s SafetyWatch initiative provides more information on handling the approach to land along with links to related ATSB investigations. 

The video can be found on the ATSB’s YouTube channel, ATSBinfo(Opens in a new tab/window).

A fatal helicopter accident on a mountain peak left two dead and one seriously injured.

A fatal helicopter accident on a mountain peak left two dead and one seriously injured.

On 8 September 2011, a chartered Eurocopter AS350BA, with a pilot and two passengers on board, was travelling to a helicopter landing site in the Shoalwater Bay military training area in Queensland. The crew were assisting in maintenance of landing sites throughout the area.  The site they were visiting was situated atop the south-eastern peak of Double Mountain. Located at an elevation of 2,421 ft, (738 m), the site was surrounded by trees on three sides with a mast and antenna array on the other.

The direction from which the pilot had approached the site was probably with a wind from the right and ... would have been vulnerable to any unexpected turbulence.

The pilot made four passes of the helipad and then, while hovering or moving at a low speed, the helicopter climbed and started to rotate left. The pilot was unable to control the rotation, and the helicopter descended into the trees before colliding in an inverted attitude with the ground. The pilot and front seat passenger were fatally injured, and the rear seat passenger received serious injuries. The helicopter was substantially damaged and there was no fire.

The ATSB’s investigation could not positively establish the reason for the pilot’s loss of control, although it is most likely to have resulted from environmental and operational factors. The direction from which the pilot had approached the site was probably with a wind from the right and, during his inspection of the site, would have been vulnerable to any unexpected turbulence.

It is part of the normal competency training for licenced helicopter pilots to receive instruction in pinnacle and confined area operations. Those skills, however, are degradable and it is vitally important to ensure that pilots’ competency and skills are appropriate to the task to which they are assigned. 

Read the final report: Loss of control involving Eurocopter AS350BA, VH-RDU, 93 km north of Rockhampton, Queensland, on 8 September 2011

A new video highlighting the ongoing safety concerns for maritime workers has been released by the ATSB today. 

The video features the accident of a crew member on board a ship who was tragically killed by an explosion while cutting a used 200 litre drum with an angle grinder.

ATSB Chief Commissioner, Martin Dolan, said the ATSB has investigated several accidents involving unsafe work practices in the maritime industry.

“We continue to investigate maritime accidents that result in serious injury or death following falls from height, crushing and exploding equipment,” Mr Dolan said.

“These accidents could’ve been avoided if the workers had just given some time to think about the risks involved before they started the task.

“The video provides a powerful reminder to all workers of the need to take risk seriously and to make sure the risk is appropriately managed.”

The video, the fourth in the ATSB’s SafetyWatch video series, can be found on the ATSB’s YouTube channel, ATSBinfo(Opens in a new tab/window).

You can find more information about unsafe marine work practices, along with the ATSB’s other top transport safety priorities, on the SafetyWatch web page. 

The ATSB today released a new YouTube video that demonstrates the serious consequences of simple, undetected human error in data calculation and entry.

The video features animation from the 2009 tail strike accident of an Airbus A340 at Melbourne Airport. In that accident, the crew inadvertently entered the take-off weight data into the aircraft’s electronic flight bag to calculate the aircraft’s take-off settings. The error passed through several subsequent checks without detection.

Through its SafetyWatch initiative, the ATSB has identified data input error as a top safety priority requiring heightened attention from the aviation industry. 

While no one is immune from data input errors, risk can be significantly reduced through effective management and systems.

While no one is immune from data input errors, risk can be significantly reduced through effective management and systems. Good communication and independent cross-checks between pilots, effective operating procedures, improved aircraft automation systems and software design, and clear and complete flight documentation will all help prevent or uncover data entry errors.

This video, along with a series of others, can be found on the ATSB YouTube channel(Opens in a new tab/window). 

The ATSB has completed its safety review of the interstate rail line between Melbourne and Sydney, identifying underlying issues and evaluating the response of the operator.

In 2007, the Australian Rail Track Corporation (ARTC) embarked on a major investment program to upgrade the rail track between Melbourne and Sydney. Since the program began, there have been a number of incidents and the condition of the line has attracted adverse comment regarding its safety, mostly in relation to rough rides and the development of mud-holes. 

On 16 August 2011, the Hon Anthony Albanese MP, Minister for Infrastructure and Transport, requested that the ATSB undertake an investigation to examine the safety of the line’s operations. 

While the treatments applied to date are likely to correct most ballast and drainage problems, the treatments are unlikely to correct the more deep-seated formation problems.

Among various issues, the ATSB investigation found that the track structure between Melbourne and Sydney had historically been particularly vulnerable to degradation in vertical alignment, resulting in the mud-holes and poor ride quality. While this was the result of a number of factors, major contributors were ballast fouling (contamination of the aggregate material laid between the formation and the rails and sleepers) and the weakness of the track formation (the earthwork foundation on which the track was laid).

In some locations, the track upgrade has increased this pre-existing vulnerability as a result of the process of installing new concrete sleepers. 

The track deterioration following the re-sleepering works has required both short-term management and the development of a longer-term major rectification program to maintain the operational effectiveness of the track. Until that rectification takes place, the safety of train operations has been maintained largely through the application of speed restrictions. These speed restrictions, together with increased maintenance activities, have resulted in extended train running times along the corridor.

While the treatments applied to date are likely to correct most ballast and drainage problems, the treatments are unlikely to correct the more deep-seated formation problems. Unless additional treatments are applied to improve the formation, it is possible that water will continue to weaken the structure in some locations. That would, in turn, require an increased regime of track maintenance (or some localised formation reconstruction) and the application of new or further speed restrictions.

The ATSB is satisfied that, taken as a whole, the necessary steps have been taken to address any issues that might otherwise compromise the safety of rail operations on the Melbourne to Sydney line where track quality is below acceptable operational standards. However, the actions taken to ensure safe operations have come at the expense of operational efficiencies through increased train running times.

Read the report: Investigation of rail operations on the interstate rail line between Melbourne and Sydney

The ATSB is urging aircraft owners and registration holders to review their maintenance schedules after a Cessna pilot’s control difficulties were found to be caused by component fractures and cracking.

The ATSB is urging aircraft owners and registration holders to review their maintenance schedules after a Cessna pilot’s control difficulties were found to be caused by component fractures and cracking.

The ATSB is strongly encouraging registration holders of class B aircraft to review their aircraft’s maintenance schedule to determine if it is the most appropriate for their aircraft and to ensure that it adequately provides for the continuing airworthiness for their aircraft.

This warning comes after a 12 September 2011 incident when the pilot of a Cessna 210 aircraft was conducting low-level aerial surveying near Bourke Aerodrome, New South Wales. After briefly encountering turbulence, he had difficulty making elevator control inputs and maintaining height. He was able, however, to land the aircraft safely with no injuries.

The ATSB has issued two safety recommendations to CASA as part of this investigation.

The ATSB investigation found that the control difficulties resulted directly from the fracture of the aircraft’s two horizontal stabiliser rear attachment brackets. The forward spar of the horizontal stabiliser was also extensively cracked. The fractures and cracking were all consistent with metal fatigue and typical of the damage that can be sustained by aircraft as they age. Many manufacturers have addressed the growing potential for this type of damage by introducing supplemental inspections to the principal aircraft maintenance requirements.

Some registration holders of class B aircraft, however, believed that their aircraft were exempt from the manufacturer’s supplemental inspections as long as the aircraft were maintained using the CASA maintenance schedule. This belief sprang from a misinterpretation of the Australian Civil Aviation Regulations 1988 (CAR). The CASA maintenance schedule did not make any specific reference to the incorporation of the manufacturer’s supplemental inspections, but it was a CAR requirement that all aircraft be maintained in accordance with approved maintenance data that, by definition, included those inspections.

The ATSB has issued two safety recommendations to CASA as part of this investigation. The first recommends that CASA proceed with its program of regulatory reform to ensure that all aircraft involved in general aviation operations are maintained using the most appropriate maintenance schedule for the aircraft type. The second is to ensure that the provisions of CAR Schedule 5 are clarified in relation to the incorporation of all relevant supplemental inspections specified for the aircraft type.

Read the final report: Flight control system event involving Cessna 210N, VH-JHF, 48 km west of Bourke Airport, New South Wales, on 12 September 2011

The Australian Transport Safety Bureau is supporting Rail Safety Week, which is being held from 12 to 18 August 2013. In its eighth year, Rail Safety Week is an initiative of the Australasian Rail Industry and aims to raise awareness of safety issues around railway lines.

During the week, the ATSB will highlight the ongoing concerns of safe work on rail. We’ve investigated several accidents that have occurred when maintenance work was being carried out on or near railway tracks. Through our SafetyWatch initiative, we urge industry to give heightened attention to the risks and hazards facing rail workers. 

A new video can be found on the ATSB’s YouTube channel (ATSBinfo)(Opens in a new tab/window) highlighting rail worker safety.

ATSB report into a collision between two road rail vehicles that left one driver trapped and seriously injured while five other people sustained minor injuries.

The Australian Transport Safety Bureau (ATSB) has released its preliminary investigation report into a collision between two road rail vehicles that left one driver trapped and seriously injured while five other people sustained minor injuries.

The accident occurred on 4 June 2013, on the West Coast Wilderness Railway in Tasmania. The road rail vehicles used on the railway are trucks designed to travel on both the road and on train tracks. When they transition from the road, they use front and rear sets of rail guidance wheels, which are lowered when the vehicle is positioned on the track. On the day of the accident the track workers placed the road rail vehicle on the track and were preparing to travel to a worksite near Rinadeena Station when it unexpectedly started to roll backwards. The driver was unable to slow the vehicle, so he and the passenger jumped clear, suffering minor injuries.

The vehicle continued to accelerate, out of control, down the steep slope, heading towards a second road rail vehicle containing four track workers.

The now-unmanned vehicle continued to accelerate, out of control, down the steep slope, heading towards a second road rail vehicle containing four track workers. Two passengers of the second vehicle jumped clear, sustaining minor injuries, but a third passenger and the driver were still inside when the unmanned road rail vehicle collided with theirs, pushing it back about 40 m along the track. The passenger sustained minor injuries, but the driver was trapped and seriously injured in the collision. He was subsequently removed from the vehicle and air lifted to hospital. Both road rail vehicles were extensively damaged.

The preliminary ATSB investigation has found that the first vehicle’s rear road-going tyres were lifted from the track during an inspection of the rear rail guidance wheels. As a result, the braking force provided by them was lost and the vehicle began to roll down the grade. The investigation has also found that West Coast Wilderness Railway had not considered all of the risks associated with operating road rail vehicles on the steep railway and, therefore, had not identified the need for operator specific procedures and training.

While the investigation is ongoing, the ATSB is encouraging all rail organisations that operate road rail equipment to consider the advice in safety alert RISN Number 7/2012 Risk associated with Hirail Operations (issued by the Department of Infrastructure, Energy & Resources, Tasmania).

Read the preliminary report: Collision between two road-rail vehicles near Rinadeena, Tasmania, on 4 June 2013

• Safe work on rail video(Opens in a new tab/window)
• SafetyWatch