The ATSB has just released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 18 covers short, office-based investigations. 

The bulletin covers incidents, serious incidents and accidents involving jet, turboprop and piston aircraft and helicopters. None of the accidents were fatal; however, some of the aircraft sustained substantial damage and, in some occurrences, people suffered injuries.

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:

• Significant wind change during take-off involving Boeing 737, VH-VZL 
• Aircraft proximity event between a Piper PA-28, VH-PZK and a Cessna 441, VH-VEJ
• Aircraft proximity event between a Beech B200C, VH-AMQ and a Ventus glider, PH-1234
• Aircraft proximity event between a Beech B200C, VH-VAE and an unidentified glider
• Wirestrike involving an Ayres Thrush S2R-T34, VH-HAH
• Power loss (both engines) involving Piper PA-39, VH-RMA
• Aircraft proximity event between a Piper PA-44, VH-MHZ and a Hawker G36, VH-JKL
• Engine failure involving a Cessna 182R, VH-OWZ
• Wheels up landing involving a Cessna 337F, VH-JUP
• Loss of control involving Robinson R22, VH-HGI

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 18

Pilots are being urged to remain focused at all stages of flight following an in-flight distraction that resulted in a fatal accident.

Pilots are being urged to remain focused at all stages of flight following an in-flight distraction that resulted in a fatal accident.

The accident occurred on 4 February 2012 shortly after a Robinson R44 helicopter lifted off from Jaspers Brush Aerodrome, near Nowra in NSW.  

During the lift off, the pilot’s door, which was not securely latched, swung open. The ATSB found that when reaching out to shut the door, the pilot likely let go of the right-hand (cyclic) control. This resulted in the helicopter abruptly pitching nose-up then steeply nose-down. It then rolled to the right and the right landing gear skid and main rotor blades struck the ground. Before the helicopter came to a stop, a fuel-fed fire started around the fuel tanks and lower mast area. Tragically, both occupants of the helicopter died in the accident.

In response to this and a number of other fatal R44 helicopter accidents, the helicopter manufacturer designed rubber bladder-type fuel tanks to replace the original all-aluminium tanks in the R44 and produced a Service Bulletin mandating their fitment.

This was not the first Robinson R44 helicopter accident to result in fatalities from post-impact fire. R44 helicopters which have all-aluminium fuel tanks have proven susceptible to post-accident fuel leaks as a result of an otherwise relatively low-energy impact, increasing the risk of a post-impact fire. In response to this and a number of other fatal R44 helicopter accidents, the helicopter manufacturer designed rubber bladder-type fuel tanks to replace the original all-aluminium tanks in the R44 and produced a Service Bulletin mandating their fitment. The Civil Aviation Safety Authority (CASA) and the ATSB have separately highlighted the safety benefits of retrofitting R44 helicopters with the bladder-type tanks.

The ATSB also issued a Safety Advisory Notice and, following another accident at Bulli Tops, near Wollongong, NSW in which a post-impact fire proved fatal, a Safety Recommendation regarding the dangers of the all-aluminium fuel tanks in the R44. Information on the safety benefits of the installation of bladder-type fuel tanks in the R44 was also circulated through the ATSB’s SafetyWatch web initiative.

Finally, on 29 April 2013 CASA issued an airworthiness directive requiring R44 helicopters fitted with all-aluminium fuel tanks to be retrofitted with bladder-type tanks and clarifying that aircraft being maintained in accordance with the Manufacturer’s Maintenance Schedule are already required to comply with all Robinson Service Bulletins in accordance with Civil Aviation Regulation 42A. More details on airworthiness directive AB/R44/23 can be found at the CASA website.

Read the final report, Loss of control involving Robinson R44 helicopter, VH-COK, Jaspers Brush Aerodrome, New South Wales, on 4 February 2012, on the ATSB website.

R44 accident site at Jaspers Brush, NSW

Robinson R22 helicopter pilots are being reminded to know the limits of their aircraft following the release of the ATSB investigation report into the reliability of the R22 belt drive system.

Robinson R22 helicopter pilots are being reminded to know the limits of their aircraft following the release of the ATSB investigation report into the reliability of the R22 belt drive system. 

The ATSB conducted the investigation in response to several R22 accidents and serious incidents caused by the failure of one or both rotor drive v-belts. Between 2004 and 2012, there were eight occurrences reported to the ATSB. The v-belts are crucial components which transmit engine power to the helicopter's main and tail rotor blades.

Pilots, operators and maintainers should pay particular attention to the installation and condition of R22 drive belts and other components of the drive system.

The report identifies a number of key factors that affect the reliability of the R22 drive belt system. These include:

• flying the aircraft with too much weight on board
• pushing the aircraft’s engine beyond its limits
• failing to maintain the drive system or ensuring the drive sheaves are aligned
• failing to conduct adequate or frequent inspections of the rotor drive system. 

During the investigation, the ATSB issued a safety advisory notice, cautioning Robinson R22 pilots of a drive belt risk and urging them to check their R22 helicopter drive system regularly for misalignment, abnormal wear or other indications of drive belt damage. 

The Robinson R22 helicopter is the most popular light utility helicopter used in Australia and has a reputation for being an extremely reliable machine. As of June 2012, there were over 500 Robinson R22 helicopters on the Australian Civil Aircraft Register. 

Owners and operators should fully appreciate the nature and effects of the operational stresses placed on the helicopter, particularly if the machine is used in a dynamic and demanding way.

Read the full investigation report, AI-2009-038 – Reliability of the Robinson R22 helicopter belt drive system.

Shipping accidents are more frequent than is widely believed but most of these accidents are preventable according to a new ATSB maritime safety report released today.

Shipping accidents are more frequent than is widely believed but most of these accidents are preventable according to a new ATSB maritime safety report released today. 

The report analyses the shipping statistics of accidents and safety incidents involving Australian-registered trading vessels (cargo and passengers) around the world or those involving trading vessels flying foreign flags within Australia’s maritime jurisdictions.

The safety of crew and shipboard workers is a significant concern for the ATSB and is highlighted as a priority in the ATSB’s SafetyWatch initiative.

Between 2005 and 2012, 245 people were killed, missing or seriously injured from reported marine occurrences. In 2012 there were 6 deaths and 33 serious injuries involving crew and shipboard workers. 

Tragically, the ATSB has found that many of these accidents were avoidable. The safety of crew and shipboard workers is a significant concern for the ATSB and is highlighted as a priority in the ATSB’s SafetyWatch initiative.

In 2012, there were 154 marine safety occurrences reported to the ATSB. This was over 50 per cent higher than the 2005–12 average of 100 occurrences each year. The increase in occurrences in 2012 was due to substantial increases in the number of reported ‘incidents’ (137) and ‘serious incidents’ (12). 

Bulk carriers and cargo vessels (including container, roll-on – roll-off cargo, heavy lift and livestock ships) have been the most common vessels involved in occurrences since 2005 and their involvement increased substantially in 2012. There were also increases in the involvement of tankers, offshore support vessels and tugs. 

The number of foreign vessels involved in occurrences grew considerably in 2012. This was predominantly due to an increased involvement in incidents (up 55 per cent on 2011), but there were also more foreign registered vessels involved in serious incidents. The number of Australian registered vessels involved in occurrences also increased in 2012 and the highest number of occurrences recorded was by Australian, Panamanian and Singaporean registered vessels. 

The ATSB is encouraging operators to learn from the experiences of others in the industry to help identify the safety risks in their operation that could lead to a similar accident or serious incident.

Read the full research report, Australian Shipping Occurrence Statistics 2005 to 2012 (MR-2013-002).

The ATSB has just released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 17 covers short, office-based investigations. 

The bulletin covers incidents, serious incidents and accidents involving jet, turboprop and piston aircraft and helicopters. None of the accidents were fatal; however, some of the aircraft suffered substantial damage and in one of the occurrences, there were serious injuries.

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:

• Wake turbulence event involving a Boeing 737, VH‑YIO 
• Windshield cracking event involving a Cessna Aircraft 750, VH-RCA 
• Airspace related event involving Beech 1900C, VH-KFN and Aerospatiale AS350 B2, VH-VRW
• Runway loss of separation between Bombardier DHC-8, VH-ZZJ and Aerospatiale, VH-LOJ
• Pilot incapacitation event involving a Hawker B200, VH-FDT
• Loss of separation involving a Cessna 310, VH XXT and a Cessna 210, VH RQD
• Engine failure involving Cirrus SR22, VH-WYH 
• Loss of performance involving DH-82A (Tiger Moth), VH-DDA
• Aircraft proximity event between an Alpha Aviation R2160, VH-NZT and a Diamond DA 40, VH-UNH
• Loss of control involving a Robinson R44, VH-RYO

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 17

The ATSB is concerned that a significant number of R44 helicopters are at risk of fire after an accident because their fuel tanks have not been retrofitted with a safety improvement.

The ATSB is concerned that a significant number of R44 helicopters are at risk of fire after an accident because their fuel tanks have not been retrofitted with a safety improvement. 

In its preliminary investigation report, released today, into last month’s fatal R44 helicopter accident at Bulli Tops in NSW, the ATSB highlights the similarities of this accident with others involving R44 helicopters with all-aluminium fuel tanks.

The Bulli Tops accident occurred on 21 March when an R44 helicopter caught fire after striking a tree and colliding with the ground. The pilot and three passengers died in the accident. The circumstances of this accident are consistent with two recent R44 accidents in Australia where the all-aluminium fuel tank ruptured, resulting in a fuel-fed fire after impact. 

The ATSB remains concerned at the significant risk facing many R44 helicopters and has recommended that CASA take further action to ensure compliance with the manufacturer’s service bulletin.

The Robinson Helicopter Company (the R44 manufacturer) had previously issued a service bulletin that requires owners to replace the all-aluminium fuel tank with a bladder-type tank before 30 April 2013. Bladder tanks substantially reduce the risk of a post-impact fire.

Australia’s aviation safety regulator, the Civil Aviation Safety Authority (CASA), confirmed to the ATSB that most owners of R44 helicopters are legally required to replace their fuel tanks before 30 April 2013. Despite this, the ATSB has assessed that about 100 Australian R44 helicopters will not have met the service bulletin by the due date 

The ATSB remains concerned at the significant risk facing many R44 helicopters and has recommended that CASA take further action to ensure compliance with the manufacturer’s service bulletin. CASA subsequently issued an Airworthiness Bulletin reminding registered operators of R44s about their maintenance responsibilities and making it clear that CASA would regard as deficient any system of maintenance that did not include the service bulletin.

The fitment of bladder-type fuel tanks to R44 helicopters is a very important safety enhancement that could save lives. The ATSB has also suggested that regulators and investigation agencies in other countries take note of its preliminary report and consider what steps they can take to increase compliance with the manufacturer’s safety bulletin.

Read the preliminary report: Collision with terrain involving Robinson R44 helicopter, VH-HWQ, at Bulli Tops, near Wollongong, New South Wales, on 21 March 2013

The ATSB’s Chief Commissioner, Martin Dolan, has just published his latest blog post 'Lending a hand overseas'.

The ATSB’s Chief Commissioner, Martin Dolan, has just published his latest blog post. In the post, Martin talks about how the ATSB has helped many countries with their transport safety investigations.

The ATSB has just released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 16 covers short, office-based investigations conducted over the past nine months. 

The bulletin covers incidents, serious incidents and accidents involving turboprop and piston aircraft, helicopters, and an incident involving an unmanned aerial system. None of the accidents were fatal; however, some of the aircraft suffered substantial damage and one of them was destroyed.

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:

• TCAS advisory involving Bombardier DHC-8-315, VH-SBG
• Airspace related event involving Kingair, VH-VAH and Ag-Cat, VH-IFE
• Runway excursion involving Cessna 210N, VH-WPD
• Aircraft proximity event involving a Cessna 172S, VH-VMM and a Schweizer 269C-1, VH-FTR
• Collision with terrain involving Cessna 172N, VH-JGR
• Aircraft proximity event between two Piper PA-28 aircraft, VH-LXH and VH-TAU
• Runway excursion involving Cessna T210, VH-DQI
• Hard landing involving Robinson R44 VH-HYR
• Loss of control involving Robinson R22, VH-HTD
• Airspace incursion involving unmanned airship, Airship 11

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 16

A new booklet released by the ATSB today dispels the myth that experience will always protect pilots from an accident.

A new booklet released by the ATSB today dispels the myth that experience will always protect pilots from an accident.  

The booklet Experience won’t always save you: Pilot experience is not always a protection against an accident, is the latest release in the ATSB’s well-received Avoidable Accidents series.  

“There’s a reverence for those who have been flying a long time,” said Dr Stuart Godley, the manager of the ATSB’s Research Investigations and Data Analysis. “We like to believe that they’ve got the right stuff, that they know themselves and their aircraft, and they can draw on their wisdom to keep themselves safe. There are many famous accidents where it appears that pilot experience has made all the difference.”

These were experienced pilots
who knew their business, but it wasn’t enough to keep them safe.

 “However, a closer analysis of these accidents suggests that things other than experience alone have always also played a significant part in saving the day,” continued Dr Godley, “but they tend not to be emphasised in anecdotes and media.”

“On the other hand, fatal outcomes can and do happen to very experienced pilots, leading to questions of how could such a thing happen to someone with so much flying behind them.”

In creating this booklet, the ATSB has drawn on its investigation archives of 20 years to find case studies that illustrate how a fatal accident can happen to anyone, even those who have been flying for years. These examples cover a range of operations and aircraft types, and each one analyses the accident, breaking down the decisions and factors that contributed to the final, fatal result. 

“These were experienced pilots who knew their business,” said Dr Godley, “but it wasn’t enough to keep them safe.”

In some of these occurrences, very experienced pilots were undertaking flying that involved much higher risk. It turned out that their flying experience alone was unable to help them avoid disaster. Other accidents involved experienced pilots who may have allowed factors other than their experience to influence their actions. In other examples, the pilot’s vast experience may have even led to decisions that, in hindsight, were associated with more risk than necessary.

As with all the Avoidable Accidents booklets, Experience won’t always save you is available for free. “The book can be downloaded from the ATSB website or we’re happy to mail free copies to anyone who would like them,” said Dr Godley. “We’ve had excellent feedback on these publications—they’re a useful resource to anyone involved in flying, but we feel that this newest booklet is especially important. The issues that it examines are something that all pilots need to think about and take into account.”

Please send requests for copies of the booklet via email to atsbinfo@atsb.gov.au 

The ATSB has released a new aviation bulletin featuring nine investigation reports. The Aviation Short Investigation Bulletin Issue 15 presents short, office-based investigations conducted over the past nine months.

The Australian Transport Safety Bureau has released a new aviation bulletin featuring nine investigation reports. The Aviation Short Investigation Bulletin Issue 15 presents short, office-based investigations conducted over the past nine months. 

The bulletin covers incidents and accidents involving turboprop piston aircraft, and helicopters. None of the accidents were fatal; however, some of the aircraft sustained 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:

• Aircraft proximity event between Beech 1900, VH-EMK and Airparts FU-24, VH-HVP  (AO-2012-134)
• Weather balloon event involving Bombardier DHC-8-400, VH-LQG (AO-2012-144)
• Runway excursion involving Piper PA-39, VH-MMN (AO-2012-145)
• Wheels up landing involving Beech A36, VH-SQI (AO-2012-151)
• Landing on a closed airstrip involving a Piper PA-28R, VH-HKZ (AO-2012-155)
• Ditching involving Robinson R44, VH-CYH (AO-2012-096)
• Power loss involving Robinson R44, VH-NWD (AO-2012-136)
• Hard landing involving Cabri G2 VH-CDU (AO-2012-140)
• Controlled flight into water involving Robinson R22, VH-HOA (AO-2012-146)

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 15