The crew of a Bell 412 helicopter, were tasked to conduct a rescue in the Mount Spec area near Townsville, Queensland.

Helicopter tail rotor strike highlights importance of maintaining a good reference point in confined areas.

On 23 May 2014, at about 0810 EST, the crew of a Bell 412 helicopter, were tasked by the Queensland Emergency Medical System Coordination Centre (QCC) to conduct a rescue in the Mount Spec area about 72 km WNW of their base in Townsville, Queensland.

Due to the inaccessibility of the area by road and the reported condition of the patient, the crew planned to conduct a winching operation. The crew consisted of a pilot, an air crew officer (ACO), a rescue crew officer (RCO), a paramedic and a doctor.

The pilot established the helicopter in a hover about 100 ft above the ground facing down the slope. The ACO directed the pilot to manoeuvre the helicopter to perform the operation and remain clear of all obstacles. The doctor and RCO were winched down to the site together, and subsequently the paramedic was lowered. The pilot conducted an orbit before returning to winch the stretcher and rescue equipment down.

This incident highlights to helicopter pilots the importance maintaining a good reference point when operating in confined areas.

The pilot and ACO then departed and after about 15 minutes, returned to commence the winch recovery. The ACO directed the pilot to manoeuvre the helicopter and winched up the doctor and the stretcher. The ACO handed the visual reference over to the pilot, while his attention was focused on securing the stretcher inside the cabin.

About 1 minute later, the ACO returned to the door and observed that the helicopter had drifted back and left and he immediately directed the pilot to manoeuvre up and to the right, however the tail rotor collided with some foliage. The ACO advised the pilot. The pilot had not detected any strike, there were no abnormal indications or vibrations, and the helicopter was operating normally.

The RCO and paramedic were then winched into the helicopter and the ACO returned to the front seat. After landing, the pilot observed some ripples on the tail rotor blades. 

This incident highlights to helicopter pilots the importance maintaining a good reference point when operating in confined areas and to establish the helicopter into the safest position possible particularly while the other crew members’ attention is focused inside the cabin. It also provides a reminder to clarify understanding between crew members, as in this incident the ACO knew the tail rotor had struck foliage, and the pilot had thought it was the main rotor and based his decisions on that belief.

Read the final report: Collision with terrain involving a Bell 412, VH-ESD, 72 km west-north-west of Townsville, Queensland, on 23 May 2014

This incident provides a reminder to pilots to know your own limitations and those of the aircraft.

On 10 May 2014, an accredited Cirrus salesman conducted a sales demonstration flight of a Cirrus SR22 aircraft, registered N802DK, in the local training area, from Bankstown Airport, New South Wales, with a pilot (and potential aircraft buyer) seated in the front left seat and one passenger on board.

At about 1330 Eastern Standard Time, the aircraft departed Bankstown and the salesman, as pilot in command (PIC) elected to track towards Katoomba at about 6,000 ft above mean sea level.

This incident provides a reminder to pilots to know your own limitations and those of the aircraft.

After demonstrating a series of turns and a straight and level stall, the PIC selected 50 per cent flap, rolled the aircraft into a left turn at about 25° angle of bank, reduced the power to idle, and raised the nose of the aircraft. The right wing dropped rapidly and the aircraft entered a spin to the right. When about 2,000 ft above ground level, the PIC was unsure whether he then had enough height remaining to recover control of the aircraft, and elected to deploy the aircraft’s parachute. The rocket fired, the aircraft initially pitched up slightly and then as the parachute deployed, the aircraft pitched down rapidly into a nose low attitude. About 6 seconds after the rocket fired, the right snub line of the parachute released, followed by the left snub line, which then established the aircraft in a wings level attitude.

The aircraft narrowly avoided powerlines, collided with branches of a tree, and came to rest on a fence in the garden of a residential dwelling.

This incident provides a reminder to pilots to know your own limitations and those of the aircraft. This demonstrates the importance of thorough planning and preparation for every flight and also of re-assessing when forced to deviate from the plan, such as operating over higher terrain. Thorough passenger and student briefings conducted prior to the flight may assist in dealing with emergency situations. 

Read the final report: Loss of control involving a Cirrus SR22, N802DK, near Katoomba, New South Wales, on 10 May 2014

• If you require assistance, please telephone (toll-free, 24 hours): 1800 011 034.

We’ve all been there. The moment when you see something that just doesn’t seem quite right. There’s a problem in front of you, and while it may not have caused an accident yet, you can easily imagine how one day, maybe one day soon, it could end badly. But if you say anything, if you point out that something is being done incorrectly, this could mean trouble.

It’s a situation that’s all too common, where sometimes people won’t thank you for pointing out a problem. But there is a way for you to share your concerns and see something done about them, without fear of being identified.  The Australian Transport Safety Bureau’s (ATSB) confidential reporting scheme, REPCON, allows people with safety concerns about the rail, aviation or marine industries to disclose them to the ATSB. These reports often contain valuable information that can help the industry address unsafe procedures, practices or conditions.

Crucially, REPCON is not used to apportion blame or liability—the underpinning legislation specifically precludes information in a report being used for disciplinary purposes. As well, REPCON reports are inadmissible in evidence in a court, except where a person has committed an offence under the Criminal Code (False or misleading information) in making the report.

“REPCON is all about solving problems, and anyone can make a call to us,” explains Elaine Hargreaves, the ATSB’s team leader for confidential reporting. She oversees REPCON, and she is a woman who keeps secrets. At the core of the scheme is the assurance that no one outside the REPCON office will learn who has reported their concerns.  “I will never reveal a reporter’s identity to anyone – not even the Chief Commissioner of the ATSB.  There are people out there who will only report to us, and they do that because they know they won’t be punished for speaking their mind and sharing their concerns. We’ve received calls from all around the country, from members of the public and people working within the industry itself.”

“People will call us at any time of day,” continues Hargreaves. “They’ll lay out their basic concerns, and then we receive a written report from them.” She acknowledges that a scheme that guarantees anonymity also offers opportunities for abuse, but tremendous care is taken to ensure that a report meets the requirements of what a safety concern is. “We assess the reports thoroughly to make sure they’re not solely focussed on an industrial action, that it’s not criminal or a threat.”

If the matter is deemed to be a genuine safety concern, the report is carefully de-identified, removing all personal attributes, and information that might lead to the identification of the reporter. The ATSB also removes the names of any other individuals mentioned in the report, ensuring that people don’t abuse the program to satisfy grudges or out of spite.

From there, the REPCON office assesses the de-identified text to ensure that the report has not become so benign that there would be no chance of any safety outcomes. After all, when the report is provided to an operator, they will need enough details to find the problem.

“We forward the de-identified text back to the reporter to get their approval before we send it out,” says Hargreaves. “Nothing happens until they’re satisfied that the right message is getting passed along, and that their identity is sufficiently protected. The report can go back and forth between the REPCON office and the reporter a few times before everyone is satisfied.”

The ATSB then provides the final report to the operator, and they have five working days in which to respond. (An extension may be granted, depending on the circumstances.) The operator’s response, along with the de-identified text is forwarded to the regulator, to take whatever action is deemed necessary. The regulator is required to respond, in accordance with a signed MOU.

“Once we’ve had a response from the regulator, feedback is provided to the operator and the reporter, where they have the opportunity to provide feedback on the outcome,” says Hargreaves. “That feedback will be reviewed, and everyone is kept abreast of developments. The report is not considered closed until all avenues for addressing the safety concern have been exhausted.”

Once the REPCON case is closed, all personal information is destroyed, and the final report (with all the relevant input) is published on the ATSB website. This final report contains no information which will identify the reporter and all efforts are made to de-identify the operator involved. Only the details of the safety concerns, as well as the responses and safety actions taken by relevant organisations or government agencies are retained.  “So many important safety concerns are reported to us through REPCON,” said Hargreaves. “We publish this information so that all of industry can be aware of, and can learn from, the problems that others have encountered, and the solutions that they’ve implemented.”

You can read closed REPCON transport reports on the ATSB website, www.atsb.gov.au/REPCON.

If you have a concern about transport safety that you’re uncomfortable reporting to the operator, you can submit a REPCON report yourself, either via the REPCON webpage or the reporting line on 1800 020 505.

Pilots should consider the effect an in-flight engine failure at low altitude has on the time available to manage that failure and identify a suitable forced landing area.

On 17 February 2014, a Cessna C206 aircraft, registered VH-YOT, departed runway 05 at Newman Airport, Western Australia, at about 0526 Western Standard Time (WST) for a charter flight to Cotton Creek in visual meteorological conditions. The pilot was the only occupant.

About 3 minutes after take-off, while in the climb and at about 1,500 feet above ground level, the pilot conducted a scan of the aircraft instruments and noticed that the engine oil pressure gauge was indicating zero. All the other engine instrument indications were in the normal range and the pilot tapped the oil pressure gauge but the indicator did not move. The pilot turned the aircraft back towards Newman airport. About 1 minute later, the pilot observed sparks coming from the engine cowling near the propeller, the engine power decreased and a severe vibration was felt through the airframe. The pilot pulled the mixture control to lean cut off to stop fuel flowing to the engine as he was concerned about an inflight fire and the propeller stopped rotating.

This accident highlights the importance of pre-flight decision making and planning for emergencies and abnormal situations.

The pilot determined that he would not be able to glide to runway 23 and began a scan to locate a suitable landing area that was away from power lines in the area. The pilot located a paddock that was about 4 km from the airport that appeared to be a suitable landing area and was near a dirt road. As the aircraft got closer to the landing area, the pilot could see what he initially thought was small shrubs, was actually medium sized trees. Prior to landing, the pilot shut down all non-essential aircraft systems.

On landing, the left wing impacted a tree and the aircraft spun around 180 degrees. The left wing was bent obstructing the only cockpit exit door. The fuel system had been disrupted and fuel was quickly entering the cockpit area. The pilot shut down all remaining systems and climbed into the rear section of the aircraft. The forward section of the cargo door was obstructed by the flaps in the full down position. The pilot exited the aircraft through the rear section of the cargo door and was not injured. The aircraft was substantially damaged.

Read the final report: Engine failure involving a Cessna C206, VH-YOT, 4 km east-north-east of Newman Airport, Western Australia, on 17 February 2014

Additional reading: Managing partial power loss after take-off in single-engine aircraft

The safety of Australia’s rail workers is under examination following the launch of a systemic safety investigation by Australia’s national transport safety investigator, the ATSB.

To take around 12 months to complete, the safety issues investigation has been prompted by continuing reports of accidents and incidents that occurred while maintenance work was being undertaken on or near railway tracks.

ATSB Chief Commissioner Martin Dolan said these ongoing incidents hint at broader safety issues that continue to raise risks for rail track workers.

“Through the ATSB’s SafetyWatch initiative, we have been urging industry to give heightened attention to rail worker safety over the past several years,” Mr Dolan said.

“While many operators are continuing to improve the safety of their workers, the ATSB remains concerned about the continuing number of reported incidents involving work on track.

“This investigation will provide a national examination of rail worker safety and aim to identify areas where safety can be improved.”

The scope of the investigation will be wide ranging and include:

• examination of occurrence data to ascertain common safety risks associated with work on track accidents and incidents nation-wide
• survey of stakeholders (rail safety workers/safety managers) involved with the implementation of worksite protection systems to identify areas of concern and possible improvements in safety when carrying out work on track
• examination of the rules, procedures and forms used nation-wide to manage risk to rail safety workers arising from work on track
• examination of work practices in the coordination and communication processes/protocols employed by rail operators when managing worksite protection
• review of rail transport operators’ safety actions in response to findings arising from internal investigation and external (independent) investigations into worksite protection incidents
• examination of the interaction between organisations’ worksite protection rules and procedures and ancillary tasks associated with work on track, including the planning, preparation and application of onsite hazard assessment.

The launch of the ATSB’s systemic investigation coincides with Rail Safety Week, which aims to raise awareness about rail safety. The ATSB is participating in Rail Safety Week to highlight the ongoing concerns facing workers on track.

More information about the ATSB’s safety issues investigation and its SafetyWatch priority can be found on the ATSB website.

The ATSB would like to pay tribute to Macarthur ‘Mac’ Job who sadly passed away on Wednesday after battling cancer for a number of years. Mac was aged 88.

As a highly accomplished aviation writer and air safety consultant over many decades, Mac established a lasting legacy in promoting aviation safety in Australia. Mac’s contribution was recognised with his 2003 award of the Medal of the Order of Australia (OAM) ‘for services to the promotion of aviation safety’.

We extend our deepest sympathies to Mac’s wife, Esma, and his five children.

Read more about Mac's life:

‘Flight Safety Australia’ remembers Macarthur Job(Opens in a new tab/window)

The ATSB has just released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 33 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 33 of the Bulletin features 10 safety investigations:

Jet aircraft

• Operational non-compliance involving an Airbus A320, VH-VGU
• Flight control system event involving a Fokker 100, VH-FZO

Turboprop aircraft

• Flight below minimum altitude involving a Beechcraft 200, VH-NMW

Piston aircraft

• Engine failure involving a Cessna C206, VH-YOT
• Controlled flight into terrain, involving PA34, VH-COU
• Landing on a closed runway, involving PA28 VH-FEZ
• Loss of control involving a Cirrus SR22, N802DK
• Near collision involving a Beech BE76, VH-SRO and a Cessna 172, VH-EEM

Helicopters

• Collision with terrain involving a Robinson R22 helicopter, VH-WDB
• Collision with terrain involving a Bell 412, VH-ESD

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 33

As part of Rail Safety Week 2014 the ATSB is highlighting rail investigations and their critical safety lessons. Helping to promote the Rail Safety Week 2014 message of ‘Near miss … Near hit’ the ATSB will be spreading the word about the importance of rail safety. 

The Australasian Railway Association (ARA) created the safety campaign nine years ago to help reduce the numbers of rail incidents that occur across the nation, many of them fatal. Rail Safety Week is this year specifically focussing on getting the message out about how a split second can mean the difference between life and death. Each one of the 1,000 near misses that occur each year could just as easily be a hit that could end someone’s life and leave a grieving family behind.

The ATSB has investigated several accidents that occurred when maintenance work was being carried out around railway tracks. Through our SafetyWatch initiative Safe work on rail, we are urging industry to give extra attention to the risks faced by rail workers while working on track.

More information can be found at Rail Safety Week 2014(Opens in a new tab/window).

The ATSB is also highlighting safe work on track through our YouTube channel (ATSBinfo)(Opens in a new tab/window).

Accident highlights the importance of considering all of the factors when assessing a landing area.

On 30 April 2014, the pilot of a Cessna 172 aircraft, registered VH-MKQ, was conducting a private flight from Launceston to a landing site about 13 km south-west of Launceston, Tasmania. Prior to departing Launceston, the pilot completed two circuits with stop-and-go landings, and confirmed the brakes were operating normally.

After a flight of about 6 minutes, the aircraft arrived overhead the landing site and the pilot overflew four times to assess the field. The pilot then conducted the approach as planned, however, when on final, he determined that the aircraft was too high and too fast to land so he conducted a go-around. 

This incident highlights the importance of considering all of the factors when assessing a landing area.

On the second approach, the pilot established the aircraft on final, with full flap selected, and slightly lower and slower than the previous approach. The wheels touched down at the pilot’s selected point, and the aircraft bounced slightly. The pilot applied the brakes, and the aircraft began to decelerate, however, as he increased the pressure on the brakes, the brakes locked up and the aircraft continued towards a fence.

The pilot selected the fuel mixture to idle cut-off and the engine stopped. The aircraft collided with the fence and the nose landing gear entered a ditch. The aircraft nosed over and came to rest inverted. The aircraft was substantially damaged, and the pilot was uninjured.

This incident highlights the importance of considering all of the factors when assessing a landing area. The stopping distance required by an aircraft may vary considerably depending on the surface conditions.

Read the final report: Runway excursion involving a Cessna 172, VH-MKQ, 13 km south-west of Launceston, Tasmania, on 30 April 2014

The Australian Transport Safety Bureau is launching a new safety priority for pilots, after investigating an increasing number of accidents caused by flying with reduced visual references, such as in cloud or at night.

ATSB Chief Commissioner, Martin Dolan said the ATSB’s recently released report into a tragic accident of a Cirrus SR22 aircraft at Boxwood, Victoria last year, shows what can go wrong as light conditions deteriorate and the risks of flying increase.

The pilot was attempting to land after last light and, using a family member positioned in a motor vehicle at the end of a private runway to illuminate the runway, collided with terrain causing fatal injury.

“This accident highlights that flying with reduced visual references, can have tragic consequences,” Mr Dolan said.

To stay safe pilots should know their limits, plan ahead, be equipped, not be fooled by initial good visibility, know their position and not press on with their journey if visual cues start to deteriorate.

“Pilots need to be on the lookout for a range of circumstances that can decrease visibility, including cloud, rain, fog, smoke or haze.”

 The main risks associated with flying with limited visibility are a:

• loss of orientation, leading to loss of control of an aircraft and an uncontrolled flight into terrain and
• insufficient visibility to enable a pilot to see and avoid obstacles while remaining under control, known as a controlled flight into terrain.

“The ATSB is so concerned with the number of accidents we are investigating that are the result of flying with reduced visual cues, that we have added it to our nine official safety priorities, known as SafetyWatch,” Mr Dolan said.

“By highlighting these priorities to pilots, we aim to make them more aware of the risks and avoid making what can be catastrophic mistakes while flying.”

To stay safe pilots should know their limits, plan ahead, be equipped, not be fooled by initial good visibility, know their position and not press on with their journey if visual cues start to deteriorate.

The ATSB has produced a new video, Flying visually at night(Opens in a new tab/window) to graphically illustrate the dangers and provide detailed guidance for pilots.

The new video accompanies the publications, Visual flight at night accidents: what you can’t see can still hurt you and Accidents involving Visual Flight Rules pilots in Instrument Meteorological Conditions.

“While flying at night does have higher risks, by pilots educating themselves and remaining vigilant to the dangers, the safety of our skies can continue to improve,” Mr Dolan said.

Read more about Flying with reduced visual cues and the ATSB’s ongoing SafetyWatch priorities.