Flying visually in poor visibility continues to be a major aviation concern, following a serious helicopter accident injuring three people in Antarctica on 1 December 2013.
Flying visually in poor visibility continues to be a major aviation concern, following a serious helicopter accident injuring three people in Antarctica on 1 December 2013.
An ATSB investigation into the accident found that an Aérospatiale AS350B2 helicopter, in company with a second helicopter, was on a return flight to Davis Base, Antarctica after supporting a scientific task at a penguin rookery at Cape Darnley. The helicopters refuelled at a fuel cache on the Amery Ice shelf before flying south-east to their next refuelling stop.
Between 1993 and 2013 there were 11 accidents involving inadvertent visual flight into 'instrument meteorological conditions', such as poor weather or cloud.
The ATSB concluded that, as a result of changing weather with a rapid reduction in visual cues, and a breakdown in the pilot's scan of his flight instruments, the pilot probably became spatially disoriented while executing a right turn. The pilot was attempting to return to the previous landing site to wait until the weather improved.
ATSB Chief Commissioner Martin Dolan, said this accident serves as yet another reminder how weather can change very quickly and turn a routine flight into a tragic accident in poor visibility conditions. This is particularly the case in Antarctica.
Mr Dolan said, "Between 1993 and 2013 there were 11 accidents involving inadvertent visual flight into 'instrument meteorological conditions', such as poor weather or cloud".
"In forecast marginal weather, while alternative options such as diverting or turning back are part of the solution, pilot training and the appropriateness of the aircraft's instrumentation must also be considered."
"Pressing on into poor visibility conditions carries a significant risk of severe spatial disorientation due to powerful and misleading orientation sensations," said Mr Dolan.
Following this accident the operator introduced new helicopters with an autopilot to reduce pilot workload. They also introduced simulator training by an experienced Antarctic pilot, a situation awareness course, and training on the limitations of the radar altimeter. The operator also provides decision-making guidance for early avoidance of unexpected white-out conditions.
The ATSB has released its latest Bulletin of short investigations covering incidents involving regular passenger transport aircraft, light aircraft and helicopters.
The Australian Transport Safety Bureau has released its latest Bulletin of short investigations covering incidents involving regular passenger transport aircraft, light aircraft and helicopters.
Issue 41 of the Bulletin covers 13 safety investigations and highlights valuable safety lessons for pilots, operators and safety managers. The Bulletin also highlights important safety messages for the broader aviation community, drawing on earlier ATSB investigations and research.
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 or identified.
Issue 41 of the Bulletin features 13 safety investigations:
During the flight, one of the passengers coughed incessantly through the headset which distracted the pilot.
Accident highlights the impact a combination of distractions can have on aircraft operations.
On 12 December 2014, the pilot of a Cessna 310 (C-310) aircraft, registered VH-TBE (TBE), was completing a charter flight from Oenpelli to Jabiru, Northern Territory. On board were the pilot, two adults and three children.
TBE was one of several aircraft operating multiple flights between the two communities, and this was the fourth and final flight for the pilot that day. Due to the late arrival of a passenger on one of his earlier runs, the pilot had been delayed throughout the morning.
After departing Oenpelli, he made a left turn, and continued climbing to 2,000 ft for the short flight. An agreed local procedure between operators in this area was that flights from Oenpelli to Jabiru operated at 2,000 ft, and flights in the opposite direction at 1,500 ft.
After a distraction source has been recognised, the next priority is to re-establish situation awareness by conducting the following: Identify: What was I doing? Ask: Where was I distracted? Decide/act: What decision or action do I need to take to get back on track?
The pilot reported that the three children on board were excited and a little disruptive, and he had kept a close watch on their activities. Concurrently, the passenger seated in the front seat coughed incessantly through the headset, which distracted him. Once he had the aircraft stable, he reached over and unplugged the passenger’s headset.
After the completion of the top of descent (TOPD) checks, he manoeuvred to join a late downwind for a right circuit onto runway 27 at Jabiru. He commenced the pre-landing checks and reported verbalising “undercarriage down”, but made a decision to leave this particular action until later on final approach. He elected to keep the aircraft speed slightly higher than normal; and as per the company procedures, kept a stable power setting and profile and only made small adjustments when needed at around 300 ft. He was also mindful of a Cessna 210 aircraft close behind TBE.
He then focussed on the passengers, especially the children, and made sure that they all had their seatbelts correctly fastened prior to landing. The children were still highly excited. He normally completed the remaining memory-recall PUFF check on final approach, but on this occasion he did not.
The pilot flared the aircraft in preparation for landing. He became aware that the undercarriage remained retracted when TBE touched down on the runway centreline and he heard the propellers contacting the ground.
Mindful there was an aircraft in the circuit behind him, he used the remaining rudder effectiveness to move the aircraft slightly to the left of the runway. When the aircraft came to a stop, he checked on the welfare of his passengers and opened the door for them to exit, directing them to assemble in a safe area. After completing shutting down, he also exited the aircraft. There were no injuries to either the pilot or passengers; however, the aircraft was substantially damaged.
Safety message
This incident highlights the impact a combination of distractions can have on aircraft operations.
Research conducted by the ATSB found that distractions were a normal part of everyday flying, and generally pilots respond to them fairly and efficiently. It also revealed that 13 per cent of accidents and incidents associated with pilot distraction between January 1997 and September 2004 occurred during the approach phase of flight.
The Flight Safety Foundation suggests that after a distraction source has been recognised, the next priority is to re-establish situation awareness by conducting the following:
Identify: What was I doing?
Ask: Where was I distracted?
Decide/act: What decision or action do I need to take to get back on track?
The debris field appeared to be of man-made origin but once again it did not exhibit all the characteristics of a typical aircraft debris field.
Fugro Equator’s deep tow system detected a cluster of small sonar contacts in the southern part of the search area, 12 nautical miles to the east of the 7th arc. The sonar data was carefully analysed and categorised as Class 2 – “of potential interest but unlikely to be related to MH370.” It could not, however, be ruled out.
“We were cautious about this,” said the ATSB’s Peter Foley, Director of the Operational Search for MH370. “There were characteristics of the contact that made it unlikely to be MH370, but there were also aspects that generated interest, multiple small bright reflections in a relatively small area of otherwise featureless seabed. All the sonar data we gather goes through a detailed analysis and an exhaustive review process to ascertain its quality, coverage and most importantly any sonar contacts of interest. The analysis starts with the mission crew on board the search vessels, data is then reviewed again ashore by sonar analysts at Fugro’s office in Perth and then it is independently reviewed by the sonar experts in the ATSB’s Operational Search team. The process is methodical, meticulous and it is designed to ensure that nothing is missed. In this case we planned to resurvey the contact in more detail when the opportunity arose.”
Therefore Fugro Supporter was tasked to divert on its passage between two search areas and further investigate the contact. A high-resolution sonar scan was performed using the AUV. The high-resolution data revealed a large number of sonar contacts lying very close to the seafloor, at a depth of around 3900 metres. The majority of the contacts were comparatively small – around the size of a cricket ball – interspersed with a few larger items, the biggest being box shaped and approximately 6 metres in its longest dimension. The debris field appeared to be of man-made origin but once again it did not exhibit all the characteristics of a typical aircraft debris field.
An additional AUV low-altitude mission was then undertaken using the underwater camera to gather images of the field. Poor weather conditions, however, prevented the safe launching of the AUV for several days.
Analysis of the images this week revealed that the debris was indeed man-made, but indicated that it was actually the wreck of a ship. This wreck is previously uncharted and the imagery will be provided to expert marine archaeologists for possible identification.
“It’s a fascinating find,” said Foley, “but it’s not what we’re looking for. We’re not pausing in the search for MH370, in fact the vessels have already moved on to continue the mission. Obviously, we’re disappointed that it wasn’t the aircraft, but we were always realistic about the likelihood. And this event has really demonstrated that the systems, people and the equipment involved in the search are working well. It’s shown that if there’s a debris field in the search area, we’ll find it.”
Ship-related debris on the sea floor, including an anchor
Source: ATSB, photo by Fugro.
An additional AUV low-altitude mission was then undertaken using the underwater camera to gather images of the field. Poor weather conditions, however, prevented the safe launching of the AUV for several days.
Analysis of the images this week revealed that the debris was indeed man-made, but indicated that it was actually the wreck of a ship. This wreck is previously uncharted and the imagery will be provided to expert marine archaeologists for possible identification.
Ship-related debris on the sea floor
Source: ATSB, photo by Fugro
Ship-related debris on the sea floor. White sea stars can be seen on some of the debris while the black objects are believed to be lumps of coal
The ATSB is a proud partner of Privacy Awareness Week (PAW) 2015. This year, PAW is being held from 3–9 May
The theme for 2015 is Privacy everyday.
Australian Transport Safety Bureau (ATSB) is a proud partner of Privacy Awareness Week (PAW) 2015. PAW is an initiative of the Asia-Pacific Privacy Authorities, held every year to promote awareness of privacy issues and the importance of the protection of personal information. This year, PAW is being held from 3–9 May.
The theme for 2015 is Privacy everyday. Privacy should be an essential component of everyday life, including in transactions such as internet banking, social media and online shopping. We recognise that our customers value their privacy, and we make your privacy important to us everyday.
You can find out more about how we protect you privacy by reading our privacy policy, which is available on our website at www.atsb.gov.au. Our policy addresses the following issues:
the types of personal information collected and held by the ATSB (including sensitive information);
how and why we collect personal information;
how the ATSB stores personal information;
use and disclosure of personal information (including overseas disclosure);
how you can access and correct your personal information; and
A new memorandum of understanding (MoU) between Australia’s transport safety investigator and civil aviation safety regulator places a renewed emphasis on cooperation to improve aviation safety.
A new memorandum of understanding (MoU) between Australia’s transport safety investigator and civil aviation safety regulator places a renewed emphasis on cooperation to improve aviation safety.
Mr Martin Dolan, the Chief Commissioner of the Australian Transport Safety Bureau (ATSB), and Mr Mark Skidmore, the Director of Aviation Safety, Civil Aviation Safety Authority (CASA), signed the new MoU on 30 March 2015.
Mr Dolan said, ‘the MOU spells out how the two agencies will cooperate in the interests of improving aviation safety. We are working together—with the ATSB identifying safety issues through its investigations and findings, and CASA and the industry responding to those issues, as appropriate—to promote high standards of aviation safety.’
The MoU contains protocols for interactions between the two agencies. It covers notifications of accidents and incidents and procedures around access to evidence, exchange of information and initiating safety action.
Significantly, both agencies have reiterated a commitment to tell the other agency about matters they reasonably believe the other agency needs to know for safety purposes.
Mr Skidmore said, ‘It is important for the agencies to share safety information while recognising that there are limits to what the accident investigator can provide to the regulator. CASA will only ask for information if it is clearly in the interests of safety. The ATSB makes the decision on what information is provided to CASA. If CASA has information it believes relevant to an ATSB investigation, it will let the ATSB know.’
The MoU is for three years with an annual review of its content.
The ATSB has released its latest Bulletin of short investigations covering incidents from November last year through to February this year.
The Australian Transport Safety Bureau has released its latest Bulletin of short investigations covering incidents from November last year through to February this year.
Issue 40 of the Bulletin covers 10 safety 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 or identified.
Issue 40 of the Bulletin features 10 safety investigations.
The Bulletin also highlights important safety messages for the broader aviation community, drawing on earlier ATSB investigations and research.
Issue 40 of the Bulletin features 10 safety investigations:
Freight within affected container, including undeclared dangerous goods, packed not in accordance with code of practice.
Fire on freight train illustrates why it’s vital that dangerous goods are packed in accordance with relevant requirements.
At about 1055 on 21 August 2014, train 3DA2, carrying containerised freight (including dangerous goods), arrived at Snowtown, South Australia. While at Snowtown, the crew noticed smoke coming from one of the containers conveying dangerous goods. The crew contacted ARTC Network Control to arrange for the Country Fire Service to attend the site. An exclusion zone was set up around the site and the fire was brought under control with minimal damage sustained.
The ATSB found that freight within the affected container, including undeclared dangerous goods, had been packed in a manner that was not in accordance with the code of practice for Transport of Dangerous Goods by Road or Rail, or the Genesee & Wyoming Australia dangerous goods policy.
Incident illustrates the importance of freight forwarders and rail operators ensuring that dangerous goods freight accepted for carriage meets the relevant requirements of the Transport of Dangerous Goods by Road or Rail code of practice.
Genesee & Wyoming Australia had a documented policy on the transportation of dangerous goods, including a Standard Condition of Carriage, which documented the obligations of GWA’s customers when providing freight for transportation. However, GWA had no active verification processes in place to check and confirm compliance with those requirements (either in total or in part through random selection). Such a process may have provided the opportunity to detect any undeclared dangerous goods or inappropriately packed freight before an incident or accident resulted.
GWA has undertaken an independent audit of their policies and procedures for consigning freight, including the adequacy of training in receiving handling and storage of dangerous goods. GWA has also undertaken to improve communications with customers at their Alice Springs and Darwin terminals – to identify where deficiencies may exist and how they might be best addressed.
Safety message
This incident illustrates the importance of freight forwarders and rail operators ensuring that dangerous goods freight accepted for carriage meets the relevant requirements of the Transport of Dangerous Goods by Road or Rail code of practice. All rail operators should ensure that their policies and procedures for the acceptance of dangerous goods are effective in ensuring that the goods accepted have been appropriately packed to minimise the risk of incidents during transportation.
Pilots encouraged to seek ATC services if unsure of their position.
ATSB investigation into a Cessna 172 accident encourages pilots, unsure of their position or requiring navigational assistance, to seek Flight Following services from ATC.
Pilots are also encouraged to regularly practise the skills required to make a safe precautionary landing.
On 27 October 2014, at about 1030 EDT, the pilot of a Cessna 172 aircraft, departed Ballarat, Victoria, for Luskintyre, NSW, on a private flight under the visual flight rules. The pilot had planned the flight carefully, and although he had adequate fuel to reach Luskintyre without refuelling, he planned to reconsider his progress at Temora, NSW, and land for additional fuel if required.
The pilot encountered some poor weather during the early stages of the flight and, although it was unplanned, he elected to land at Wangaratta, Victoria, to take a break and have some refreshments. While at Wangaratta, he also took the opportunity to add some fuel. After a short break and refuel, the pilot continued to Temora, where he elected to land for another break. The pilot re-assessed his fuel requirements at Temora, and determined that he had sufficient fuel to continue to Luskintyre with ample reserve without refuelling.
After departing Temora, the pilot planned to overfly Rylestone, Denman and Jerrys Plains, en route to Luskintyre. The flight proceeded as planned to about Kandos (just south of Rylestone), where the pilot visually fixed his position. At that point, rather than continuing as planned overhead Rylestone then on to Denman, the pilot elected to track directly to Luskintyre.
The direct track between Kandos and Luskintyre was over heavily treed and undulating terrain, leaving the pilot unable to positively visually fix his position. As he continued in an easterly direction, the pilot grew increasingly concerned about the possibility of infringing controlled airspace further to the east. Conditions at the time were windy and although the pilot recalled that the visibility was good, there may have been some bushfire smoke in the area.
Rather than risk infringing controlled airspace, the pilot decided to make a precautionary landing to ascertain his position. He located a valley that appeared to have some cleared areas, then circled for several minutes assessing precautionary landing options. The pilot commented that precautionary landing options were very limited, but he ultimately selected a paddock that was clear of obstacles, and while relatively short, it offered an uphill landing run to assist in stopping the aircraft.
During his approach to land on the selected paddock, with full flap selected, the pilot found himself overshooting the selected aim point. He endeavoured to recover the profile, but had increasing difficulty maintaining the preferred aim point. Concerned that he would not be able to land safely, the pilot elected to discontinue the approach and commenced a go-around. As the go-around proceeded however, the pilot found that he was unable to climb over tress ahead of the aircraft on rising terrain beyond the far end of the selected paddock. He was able to manoeuvre around a small number of individual trees, but collided with a line of trees, slightly further on. The aircraft was substantially damaged in the collision and the pilot received serious injuries.
The aircraft was fitted with an emergency locator transmitter (ELT) which was activated by the impact. An overflying aircraft detected the ELT signal at about 1715 EDT, and search and rescue authorities were alerted. Sometime after the accident, the pilot was also able to activate a portable locator beacon. In addition, the pilot had left a Flight Note at the point of departure. When the pilot had not made contact by the nominated time, the holder of the Flight Note commenced enquiries and notified authorities. The aircraft wreckage was ultimately discovered by a local resident, around 2 hours after the accident, independent of other search and rescue activities. The local resident alerted authorities, who attended the scene and were able to secure the wreckage and provide medical assistance to the injured pilot.
Safety message
In many cases, deviation from a flight plan is necessary to ensure continued safe flight. Where deviation from a flight plan is not essential, pilots are encouraged to consider the risk of operational complications such as potential difficulties with navigation or fuel management. Deviation from a flight plan or Flight Note may also affect search and rescue activities in the event of an accident, to the extent that a search is conducted in the wrong place.
Where available, pilots unsure of their position or requiring navigational assistance, are encouraged to seek Flight Following services from ATC. In this case, contact with ATC may have allayed the pilot’s concerns about the prospect of infringing controlled airspace, and negated the need to consider a precautionary landing. A fact sheet regarding Flight Following services is available on the Airservices Australia website via the following link, under the group heading working with air traffic control.
With respect to precautionary landings, pilots are encouraged to initiate an early go-around as soon as there is any doubt regarding the prospects of a safe landing. The potential for a safe go-around may diminish as an aircraft continues an approach, particularly where there is rising terrain or obstacles beyond the selected precautionary landing area.
...pilot's, unsure of their position or requiring navigational assistance encouraged, to seek Flight Following services from ATC.
While in this case the aircraft was found by a local resident independent of search and rescue activities, the accident nonetheless provides a reminder of the potential value of a Flight Note. Pilots are encouraged to prepare a Flight Note where relevant, and to ensure that the information provided on the Flight Note is as accurate as possible. Pilots are also encouraged to advise ATC of any deviation from the planned route, to ensure that search and rescue authorities have access to updated information where relevant.
Issue 39: The ATSB has just released a new aviation bulletin containing 10 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 39 of the Bulletin features 10 safety investigations:
