Data input errors continue to be a problem in aviation, with three recent incidents highlighting the need for greater attention to detail.

Data input errors continue to be a problem in aviation, with three recent incidents highlighting the need for greater attention to detail.

In two instances, involving a Boeing 737 and an Airbus A330, the correct loading weight was not supplied to the flight crews, prior to departure.

Incident No.1

Handlers in Bali miscalculated the number of bags loaded onto a commercial Boeing 737 flight to Melbourne. The total number of bags loaded was 189, instead of 93, with an estimated additional weight of about 1,600 kg. 

The load control team leader assessed the additional baggage weight was acceptable, that adequate fuel had been uploaded to cater for the extra weight and elected not to advise the flight crew of the discrepancy.

At the time of the occurrence there was no formal procedure to advise flight crew of a loadsheet discrepancy. However, if the flight crew were advised of loadsheet discrepancy in-flight, it is envisaged the additional weight figure would have been used to modify the approach speeds that had been generated, based on the weight entered into the flight management computer prior to departure. For an extra weight of 1,600 kg, the captain reported the approach speeds would normally increase by about 1-2 kt.

The flight arrived safely.

Second incident

In the second incident, involving an Airbus A330 flying from Perth to Brisbane, ground staff at Brisbane discovered an unlisted cargo weighing 1,467 kg that was supposed to have been offloaded in Perth.

As a result of both these incidents, the airline took several steps, including refresher training, to remedy the situation.

Incident No. 3

Loading of freight caused the pilot of a Fairchild SA227 to reject a take-off at Rockhampton.

Passing the take-off safety speed (V₁), as the pilot increased the back pressure on the control yoke to rotate the aircraft for take-off, the control column felt heavy and the aircraft nose wheel did not lift off the ground. The pilot continued to increase the back trim and back pressure on the control yoke and the ‘out of trim’ warning sounded.

After taxiing the aircraft back to the bay, the pilot requested the freight be re-weighed. He recalculated the aircraft weight and balance with the actual freight distribution and found the centre of gravity slightly more forward than the original load sheet position.

Overall, the actual freight loaded weighed about 30 kg more than that stated on the load plan. One of the aircraft’s freight ‘zones’ was loaded with 72 kg more than the placard maximum weight for that zone. A revised trim sheet was prepared using the re-weigh information and found that the aircraft was within the centre of gravity limits for the proposed flight with a centre of gravity slightly forward of the original calculated position.

Following the incident, the operator advised the ATSB it was taking several safety actions, including investigating the management of ground handling and the manner in which aircraft are loaded at all ports.

All three incidents highlight the ATSB’s broad safety concerns about data input errors, such as incorrect loading figures. The consequences of these errors can include a range of aircraft handling and performance issues.

• Read the investigation reports in the ATSB’s latest short investigation bulletin issue 36.
• More information about data input errors and the ATSB’s other transport safety priorities can be found on the ATSB’s SafetyWatch page.
• Data input errors video

The rate that aircraft are striking wildlife has reduced in the past two years following four years’ of growth.

The rate that aircraft are striking wildlife has reduced in the past two years following four years’ of growth.

Birdstrikes are the most common aviation occurrence and continue to be a significant economic risk for aerodrome and airline operators and a potential safety risk for pilots.

More than 1,500 birdstrikes  are reported to the ATSB each year.  Most involve high-capacity air transport aircraft.  However, since 2011, the birdstrike rate per aircraft movement for seven of the 10 major airports has reduced. Adelaide, Melbourne, Perth and Sydney had lower rates in 2013 than in 2004.

The ATSB’s latest biannual update of aviation wildlife strike statistics shows that although the number of birdstrikes has continued to increase for all operation types, due to increasing aircraft movements, the rate per aircraft movement has actually decreased slightly in recent years.

Domestic high-capacity air transport aircraft were those most often involved in birdstrikes, and the strike rate per aircraft movement for these aircraft was significantly higher than all other categories. However, the number of the incidents with the potential for more serious consequences due to engine ingestion is at its lowest level in 10 years.

There were 3,400 birdstrikes in 2012–13, with the four most commonly struck wildlife being kites, bats/flying foxes, lapwings/plovers and galahs.

Kites had the most significant increase in the number of reported strikes per year in the past two years, with the species being involved in an average of 129 strikes per year for 2012 and 2013, compared with 84 per year on average across the entire 10-year reporting period.

Historically, birdstrikes have not been a significant safety risk to civilian air travel in Australia. ATSB data dating to 1969 shows no civilian aviation fatalities attributed to birdstrikes.

Compared to birdstrikes, non-flying animal strikes are relatively rare. The most common animals involved were hares and rabbits, kangaroos, dogs/foxes and wallabies. Damaging strikes mostly involved kangaroos, wallabies and livestock.

“The statistics provide a reminder to everyone involved in the operation of aircraft and aerodromes to be aware of the hazards posed to aircraft by birds and non-flying animals,” ATSB Chief Commissioner Martin Dolan said.

Read the full report: Australian aviation wildlife strike statistics 2004 - 2013

The ATSB has welcomed the findings of the Transportation Safety Board of Canada’s (TSB’s) independent review into the ATSB’s investigation methodologies and processes.

Publicly released by the TSB today, the review found that both TSB and ATSB investigation methodologies either met or exceeded international best-practice standards.

The review also made 14 recommendations for improvements in how the ATSB conducts transport safety investigations.

ATSB Chief Commissioner Mr Martin Dolan said he requested the TSB to conduct the review as they have a similar legislative framework to the ATSB and a long-standing commitment to systemic investigation to improve safety.

“The TSB’s independent review has provided valuable independent insight into the ATSB’s investigation methodologies and procedures, and how these compare to international best practice,” Mr Dolan said.

“While I’m pleased to see that the ATSB mostly met or exceeded international investigative standards, there is clearly room for improvement.

“We will carefully and methodically work through the review’s findings as part of our ongoing efforts to improve our processes and procedures.

“I am sincerely grateful for the valuable time and effort our Canadian colleagues have contributed to complete this important piece of work.”

The ATSB Commission will provide TSB a detailed, formal response to the review in early 2015. This response will be made publicly available at the ATSB website.

The report of the TSB review(Opens in a new tab/window) can be found on the TSB website at www.bst-tsb.gc.ca(Opens in a new tab/window).

ATSB Media Release

The ATSB’s first report of safety trends in Australian aviation reveals that while our skies remain safe, there are some shifting trends to watch.

Released today, the report summarises trends in Australian aviation from January to June 2014, comparing it to a five-year average, and what safety action was taken to address those trends. Trends will be updated every six months in this new ATSB analysis series.

Of note in this reporting period was an increase in the rate of airborne collision alert system warnings in high-capacity air transport operations over the past five quarters (since April-June 2013).

Most of these occurred in Sydney (12 of 28 in the past six months). All of these happened during independent visual approaches (IVAs) and 10 of them on runway 34L/R. An ATSB investigation into IVAs at Sydney Airport will be completed later this year.

While control issues with high-capacity aircraft are a low frequency occurrence, there was an increase in occurrences from January to June 2014. However, 10 of 16 of these were reported by one airline. The Fokker 100 was over-represented by fleet and activity size with five occurrences.

Loss of separation incidents involving low-capacity air transport also increase in January to June. Darwin and the Northern Territory in general were the most common location for these. Most were low risk although there was one high collision risk occurrence during this six-month period.

Safety trends in Australian aviation reveals that while our skies remain safe, there are some shifting trends to watch.

Dr Stuart Godley, Manager of ATSB Reporting & Analysis, said the ATSB would continue to monitor all safety trends.

“By maintaining a constant watch on aviation safety, we can effectively gauge trends and alert and advise industry of potential safety issues,” Dr Godley said.

Read the full report: Emerging trends in Australian aviation safety

Australia’s transport industries are some of the safest in the world but more can be done to improve safety, according to the ATSB’s annual report.

• Download: ATSB Annual Report 2013-14

Australia’s transport industries are some of the safest in the world but more can be done to improve safety, according to the ATSB’s annual report.

Approved for tabling by the Deputy Prime Minister the Hon Warren Truss, the annual report highlights the ATSB’s top transport safety concerns across the aviation, maritime and rail industries.

ATSB Chief Commissioner Martin Dolan said the safety concerns bring together the ATSB’s investigation findings and analysis of the safety occurrence data reported by industry.

“We are urging industry to give heightened attention to the risk areas identified by the ATSB,” Mr Dolan said. “While we are seeing improvements in certain areas of transport safety, other risk areas remain a concern to the ATSB. We’ll continue to closely monitor these transport safety hotspots over the coming year.”

One of the year’s notable transport safety achievements was the nation-wide fit out of the bladder-type fuel tank on all Robinson R44 helicopters (in accordance with the manufacturer’s directive). The bladder tank replaced the rigid aluminium fuel tank that was highly susceptible to post-impact fires. 

The ATSB’s growing concern about accidents caused by flying with reduced visual references, such as in cloud or at night, has led to that matter being included as a top transport safety risk area identified in the ATSB’s safety priorities.

“We’ve moved to address concerns about the increasing number of accidents caused by flying with reduced visual references,” Mr Dolan said. “By highlighting these priorities to visual flight rules pilots, we aim to make them more aware of the risks and of what can be done to avoid what can be catastrophic mistakes while flying.”

Three significant investigations into flying with reduced visual cues are included in the annual report, along with features on some of the 217 investigations conducted by the ATSB in 2013–14.

The annual report also details the ATSB’s involvement as the lead organisation in the search for missing Malaysia Airlines flight MH370 that disappeared in March 2014. “Finding the missing aircraft and helping solve the mystery of its disappearance is our greatest challenge. Just as importantly, though, we continue our work to improve safety through investigating aviation, maritime and rail incidents at home,” Mr Dolan said.

Australia’s current top transport safety priorities across aviation, maritime and rail (SafetyWatch):

• Flying with reduced visual cues
• Marine work practices
• Safe work on rail
• Data input areas for aviation
• Safety around non-controlled aerodromes
• General aviation pilot risks
• Maritime pilotage
• Under reporting of occurrences
• Handling approach to land

More information on these risk areas can be found at the ATSB’s SafetyWatch web page.

Download: ATSB Annual Report 2013-14

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 35 of the Bulletin features 10 safety investigations:

Jet aircraft

• Flight envelope protection event involving an Airbus A320, VH-VFJ
• Aircraft cabin water leak event involving an Airbus A380, VH-OQD

Turboprop aircraft

• Runway incursion involving a Bombardier DHC-8, VH-QOP         

Piston aircraft

• Loss of control during landing, involving a Diamond DA40, VH-CGT
• Fuel exhaustion involving a Piper PA-25, VH-SSO
• Ground collision with a refuelling vehicle, involving a Grob G-115, VH-ZYM
• Potential fuel exhaustion event involving a DHC Beaver, VH-AWI
• VFR into IMC involving a Cessna 206, VH-NCR

Helicopters

• Ground strike and loss of control involving a Robinson R22, VH-HAY
• Wirestrike involving a Robinson R66, VH-JRX

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 35

Pilots advised the sooner a condition that warrants a go-around is recognised, the safer the manoeuvre will be.

On 13 July 2014, the pilot of a Cessna 172 aircraft, registered VH-EEC, conducted a private flight from The Lily to Narrikup aeroplane landing areas (ALA), Western Australia, with two passengers on board.

At about 1320 Western Standard Time, the pilot broadcast an inbound call when about 10 NM north-east of Narrikup at about 6,500 ft above mean sea level (AMSL). The pilot elected to conduct an approach to runway 06 and overflew the runway at about 1,900 ft AMSL. He observed the windsock which did not indicate any significant crosswind. The aircraft then descended to circuit height and joined on the crosswind leg for runway 06.

When established on final for runway 06, the pilot reported that he had selected two stages of flap and had the aircraft stabilised at about 65 kt. When about 50 ft above ground level, the pilot reported that the aircraft encountered a wind gust which carried the aircraft about 30 m to the right. The pilot moved the aileron controls into wind and applied full power to commence a go-around; however, the aircraft’s right wing collided with trees on the right side of the landing area. The pilot reported that the right wing may have stalled as he applied full right aileron. The aircraft fell to the ground resulting in substantial damage.

This incident highlights the importance of being ready to conduct an early go-around when a pilot is not completely satisfied that a safe landing can be made.

A go-around, the procedure for discontinuing an approach to land, is a standard manoeuvre performed when a pilot is not completely satisfied that the requirements for a safe landing have been met. The need to conduct a go-around may occur at any point in the approach and landing phase, but according to the United States Federal Aviation Administration (FAA), the most critical go-around is one initiated when very close to the ground. Consequently, the sooner a condition that warrants a go-around is recognised, the safer the manoeuvre will be.

The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of the safety concerns is that general aviation pilots continue to be involved in accidents that are mostly avoidable. A range of procedures and requirements exist to enable pilots to manage the hazards associated with common avoidable accident types.

The following provide useful information on go-arounds:
• Aviation safety explained – Go-arounds(Opens in a new tab/window)
•

Read the final report: Collision with a tree involving a Cessna 172, VH-EEC, 19 km north-north-west of Albany, Western Australia, on 13 July 2014

The ATSB is urging pilots of single-engine aircraft to plan for partial power loss, following the release of a new educational video.

Between 2000 and 2010, there were nine fatal accidents resulting in 20 people losing their lives as a result of a response to a partial power loss soon after take-off. Importantly, there were no fatal accidents where the engine initially completely failed.

ATSB research manager Dr Stuart Godley says the high number of fatalities and serious injuries resulting from partial power loss should be of concern to pilots and flight instructors.

Our accident data shows that for single engine aircraft, a partial power loss during and after take-off is three times more likely to occur than a complete engine failure.

“Historically, the simulated total loss of power and subsequent practice forced landing has been the core of a pilot’s emergency training,” Dr Godley says. “However, our accident data shows that for single engine aircraft, a partial power loss during and after take-off is three times more likely to occur than a complete engine failure.”

While partial power loss can be more challenging to manage—due to the number of choices and decisions confronting the pilot—Dr Godley says that the lack of training, coupled with the lack of pilot preparation and planning, may also help explain the higher number of fatalities.

“Total engine failure after take-off is part of the Day VFR syllabus and is taught and practiced throughout a pilot’s initial training. However, partial power loss after take-off is not a practiced syllabus item and probably does not receive the same emphasis during training.

“A pre-flight briefing for both a complete engine failure and partial power loss is the key to a pilot maintaining control of their aircraft.” says Dr Godley.

The new short video, available on the ATSB’s YouTube channe(Opens in a new tab/window)l (ATSBinfo) provides pilots and flight instructors advice on how to manage the dangers surrounding partial power loss in single engine aircraft.

More information about managing partial power loss in single-engine aircraft is also available in the ATSB’s avoidable accident booklet, Managing partial power loss after take-off in single-engine aircraft.

The ATSB has just released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 34 covers short, office-based investigations.

The bulletin covers incidents, serious incidents and accidents involving jet, turboprop and piston aircraft, as well as helicopters.

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.

Issue 34 of the Bulletin features 10 safety investigations:

Jet aircraft

• Cargo hold smoke event involving a Boeing 737, DQ-FJH
• Loading issue involving a Boeing 737, VH-VZO
• Loss of separation assurance involving a Boeing 737, VH-XZA and a Fairchild SA227, VH-ANW

Turboprop aircraft

• Near collision involving a B200 Kingair VH SBM, and a Piper Saratoga, VH XKS

Piston aircraft

• Engine failure involving a Piper PA 46, VH-TSV
• Collision with a tree involving a Cessna 172, VH-EEC

Helicopters

• Collision with terrain involving Robinson R22, VH-HEP
• Collision with terrain involving a Bell 206, VH-KSV
• Collision with terrain involving a Bell 206, VH-NKW
• Collision with terrain involving a Robinson R22, VH-ZZM

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 34

In-flight propeller separation involving Jabiru Aircraft J430, north of French Island, Victoria.

On 8 March 2013, during climb after departure from Tyabb aerodrome, Victoria, the pilot and sole occupant of a Jabiru J430 aircraft, reported the onset of vibration through the airframe.

As a precaution, the pilot began to turn the aircraft back towards Tyabb. During the turn, the propeller separated from the aircraft, necessitating a forced landing upon tidal flats at the western edge of Westernport Bay. The pilot was not injured and was able to disembark the aircraft safely.

A potentially serious accident was avoided by the pilot’s adherence to emergency procedures and maintaining control of the aircraft after a significant mechanical failure.

The ATSB investigation found that most of the cap screws connecting the propeller mounting flange to the engine crankshaft had failed by bending fatigue fracture – principally due to repeated relative movement between the mounted components. This movement was traced to a combination of an ineffective, multi-step torqueing method and the relaxation of tension within the crank–flange joint due to the compression of multiple layers of paint within the joint. It was also found that there were some anomalies within the maintenance documentation that related to these areas.

After attempting to analyse the origin of the worsening vibration in the aircraft, the pilot correctly followed emergency procedures both before and after the propeller loss. The over-water return decision limited the risks associated with the forced landing, and the pilot effectively maintained control of the aircraft throughout the descent and landing.

In July 2011, the manufacturer had improved the strength and reliability of the crank–flange joint by adding positive-location dowels in all new-production engines. However, that modification was not extended to earlier design assemblies, which included VH-TJP. The current (revised) issue of the Engine Overhaul Manual has an added strong recommendation for inclusion of these dowels at the next full overhaul or at bulk strip of engines manufactured prior to July 2011. Furthermore, in addition to the earlier requirement for no paint on mating faces or where screw heads bear, a broad requirement was introduced to ensure that no paint, thread-locking compound or contaminants remain in the propeller flange joint. The fastener torqueing method has been amended to a single-step process in which the required torque is to be obtained dynamically while the fastener is being turned.

Finally, the manufacturer’s Propeller Flange Attachment Service Bulletin now refers maintainers directly to the engine overhaul manual for installation procedures – removing the variability that previously existed between documents.

A potentially serious accident was avoided by the pilot’s adherence to emergency procedures and maintaining control of the aircraft after a significant mechanical failure.

Regarding the mechanical assembly, the ATSB encourages manufacturers and maintainers to consider older and legacy operating assemblies when designs are optimised or improved to enhance safety and reliability.

Read the final report: Propeller loss involving Jabiru J430, VH-TJP, north of French Island, Victoria, on 8 March 2013