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.
All mariners urged to keep a lookout after a collision between container ship and yacht off south-east Queensland.
All mariners urged to keep a lookout after a collision between container ship and yacht off south-east Queensland.
In the early morning hours of 6 July 2014 in Moreton Bay the container ship Kota Wajar collided with the yacht Blazing Keel. The yacht suffered extensive damage but remained afloat and the yacht safely returned to its marina.
The ATSB found that no one on board either Kota Wajar or Blazing Keel saw the other vessel before the collision. Neither vessel had maintained a proper lookout.
‘Back then the ATSB noted there were significant lessons to be learned from this incident and I’m concerned that the message is not getting through’, he said.
Because of the continuing safety issue around maintaining an effective lookout when navigating in Australian waters, the ATSB has issued a safety advisory notice which reinforces the importance of taking all necessary measures to ensure that a proper lookout is kept at all times.
Across the past 26 years, investigations into 41 collisions between trading ships and small vessels on the Australian coast have identified that maintaining a proper lookout is paramount to preventing collisions.
Pilots must operate within personal limits when flying in darker environments.
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.
This report summarises significant trends in Australian aviation from July to December 2014, and resultant safety action being taken to address these trends.
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
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.
The Chief Commissioner of the ATSB, Mr Martin Dolan has welcomed the re-appointment of Mr Noel Hart as a Commissioner.
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.
Two crew were seriously injured by a falling load spreader. The ATSB identifies some simple safety precautions that must apply to crane operations.
On 23 February 2015, two crew were seriously injured by a falling load spreader on Happy Buccaneer in Port Hedland, Western Australia.
A technician and the bosun had worked together to remove a sling hook from lowest of a pack of four load spreaders. Each load spreader was 4 m long by 1.2 m wide and weighed 2.4 t. The pack of four had not been secured into a single unit prior to being lifted.
After removing the hook, and as the two men walked alongside the stacked load spreaders, the bosun signalled to the crane operator to raise the crane’s hook. As the hook was raised a hammerlock (joining link) on the chain sling most likely caught the lip of the topmost load spreader, tipping it off the pack and onto the two men.
The technician’s right leg was pinned under the load spreader and he had fractured both legs.
The technician’s right leg was pinned under the load spreader and he had fractured both legs. The bosun was not trapped but suffered fractures to his lower left leg. Both men required extensive surgery and the technician also had his right leg amputated below the knee.
The ATSB identifies some simple safety precautions that must apply to crane operations.
Lifting and handling procedures and practices should use a risk assessment to anticipate the hazards and to minimise the associated risks.
Crane operators, banksmen (dogmen) and assisting crew should be aware of each other’s location and the movement of suspended loads.
Rigging gear needs to be guided until it is free of obstacles and equipment.
Multiple loose items need to be combined and secured to form a single unit prior to lifting.
Clear communications by hand, radio or other methods must be practiced and emphasised during lifting operations.
A light aircraft collision between a Piper PA-28 and Cessna 172 shows why it’s crucial to manage and respond to partial power loss immediately.
A light aircraft collision between a Piper PA-28 and Cessna 172 shows why it’s crucial to manage and respond to partial power loss immediately.
Summary
On 11 April 2015, a Piper PA-28 aircraft suffered engine problems after take-off and the student pilot attempted to return immediately to Moorabbin Airport. As the Piper landed, it touched down about one third of the way along the runway. The pilot attempted to slow the aircraft, and its left wing collided with the tail of a Cessna 172 aircraft, which was waiting on an adjacent taxiway.
The pilot of the Piper was not injured but the pilot and passengers of the Cessna were treated for minor injuries. Both aircraft sustained substantial damage.
The incident was a good example of how quickly things happen; about 90 seconds after an aircraft took off it was back on the ground and at least two aircraft had to be sent around in the interim.
The ATSB advises that a pre-flight safety brief that considers actions to take following a partial power loss after take-off, will give pilots a much better chance of maintaining control of their aircraft and of responding immediately. The ATSB publication Avoidable Accidents No. 3 – Managing partial power loss after take-off in single-engine aircraft gives more information to pilots.
Incident in detail
On 11 April 2015, the student pilot of a Piper PA-28 aircraft, registered VH-TXH, taxied at Moorabbin Airport, Victoria, for a solo flight to the local training area. At about 1136 Eastern Standard Time, the aerodrome controller – east, cleared the Piper for take-off.
At about 1137, the pilot of a Cessna 172 aircraft, registered VH-EUU, contacted the surface movement controller and requested a clearance to taxi for a local private flight, with three passengers on board. The surface movement controller cleared the Cessna to taxi to runway 35R via taxiway A, and the pilot began taxiing.
The pilot of the Piper reported that the take-off run was normal, but after rotation, the engine intermittently ran roughly, and then regained full power. At about 1138, the pilot advised the aerodrome controller - east of engine trouble and requested a return to land. The controller observed that the Piper did not appear to be climbing out normally and was then quite low, and offered the pilot runways 22 or 31 if required. The pilot elected to use runway 22.
The aerodrome controller – east advised the surface movement controller and the aerodrome controller – west of an aircraft with engine trouble, and coordinated with the surface movement controller for runway 22. At about 1139, the aerodrome controller – east cleared the Piper to land. The pilot of the Cessna conducted a tight right turn towards runway 22 and the aircraft touched down about one third of the way along the runway. The aerodrome controller – east and the surface movement controller observed that the Piper appeared to be travelling too fast to stop before the end of the sealed runway.
The pilot of the Piper assessed that he was not going to be able to stop the aircraft before the end of the sealed runway, but that there was a suitable grassed overshoot area beyond. The aerodrome controller – west was standing up, sighted the Cessna on taxiway A, and alerted the surface movement controller. As the Piper approached the end of runway 22, the pilot sighted the Cessna on taxiway A to his right, and veered to the right in an attempt to pass behind the Cessna. The surface movement controller directed the Cessna to stop. The pilot of the Cessna braked immediately and sighted the Piper, but assessed that if he stopped there, the Piper would collide squarely with the Cessna, so he released the brakes and progressed forwards. The left wing of the Piper then collided with the tail of the Cessna.
The pilot of the Piper was not injured. The pilot and passengers of the Cessna were treated for minor injuries. Both aircraft sustained substantial damage.
A post-accident inspection of the Piper’s engine found a small quantity of oil on the cylinders and some fouling of the spark plugs which may have led to the rough running.
Safety message
The ATSB publication Avoidable Accidents No. 3 – Managing partial power loss after take-off in single-engine aircraft, found causes of partial power loss after take-off include fuel starvation, spark plug fouling, carburettor icing and pre-ignition conditions. A pre-flight safety brief that considers actions to take following a partial power loss after take-off, gives pilots a much better chance of maintaining control of the aircraft and of responding immediately. Such actions include landing immediately within the aerodrome, landing beyond the aerodrome, and conducting a turn back towards the aerodrome.
A fatal Robinson R44 helicopter accident has prompted the ATSB to recommend safety improvements to helicopter fuel tanks in the United States and Europe.
A fatal Robinson R44 helicopter accident has prompted the ATSB to recommend safety improvements to helicopter fuel tanks in the United States and Europe.
Four people died in the March 2013 accident at Bulli Tops in New South Wales. The R44 helicopter they were travelling in was engulfed in fire after striking a tree and hitting the ground.
Following this accident, Australia's Civil Aviation Safety Authority, and other international regulators, made it mandatory for R44 helicopter operators to replace the R44's all-aluminium fuel tank with a bladder-type fuel tank.
ATSB Chief Commissioner Martin Dolan said that bladder-type fuel tanks reduce the risk of post‑impact fire in the R44. But the ATSB remains concerned at the risk of post-impact fire in helicopters not fitted with crash-resistant fuel systems.
'We believe the US Federal Aviation Administration (FAA) and the European Aviation Safety Agency (EASA) can help improve the safety of many helicopter pilots and their passengers,' Mr Dolan said.
'We have issued safety recommendations to the FAA and EASA. We ask them to take action to increase the number of crash-resistant fuel systems fitted to existing and newly-manufactured helicopters.
'Under international convention, we would expect to hear from the FAA and EASA about their proposed responses to these recommendations by early September 2015,' Mr Dolan said.
The Bulli Tops accident was similar to other R44 accidents involving fatal post-impact fire that made survivability impossible. In each case, the R44s were fitted with all-aluminium fuel tanks.
Mr Dolan said, 'Statistical analysis of accidents in Australia and the United States over ten years found a higher proportion of post-impact fires involving R44s than for other similar helicopter types.'
The analysis also identified that, despite a 20-year-old requirement for new helicopters to have a crash-resistant fuel system, several helicopter types are being made without such a system. In addition, although modification kits are available for a number of helicopter types, they have not been incorporated in many of the existing civil helicopter fleet.
Recent news reports about the search for MH370 have included highly inaccurate assertions about the search and how it is being conducted.
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.”
