It's important that pilots with experience, familiarity and comfort with the aircraft and location, continue to do all checks thoroughly.

On 23 February 2014, a Hughes 269C helicopter, was parked on a property about 55 km north-east of Launceston, Tasmania, beside a dam. The pilot had shut the helicopter down in that position about a week earlier, aware that it was low on fuel.

At about 0700 Eastern Daylight-savings Time (EDT), the pilot prepared for a short 200 m flight to reposition the helicopter to the other side of the dam, for refuelling. He conducted fuel drains, with no contaminants found.

While experience and familiarity with operations are invaluable, they can also lead to complacency.

The helicopter took off and climbed to about 20 ft above ground level. When about three quarters of the way across the dam, the engine stopped due to fuel exhaustion. The pilot conducted a forced landing onto the edge of the dam, with part of the helicopter sinking into the water and mud. The main rotor blades collided with the embankment resulting in substantial damage.

While experience and familiarity with operations are invaluable, they can also lead to complacency. It is therefore important that pilots with experience, familiarity and comfort with the aircraft and location, continue to do all checks thoroughly.

Read the final report: Collision with terrain involving a Hughes 269C, VH-HAK, 55 km north-east of Launceston Airport, Tasmania, on 23 February 2014

Additional reading:

• Avoidable Accidents No. 5 – Starved and exhausted: Fuel management aviation accidents
• Avoidable Accidents No. 6 - Experience won’t always save you

Australian Transport Safety Bureau (ATSB) is a proud Privacy Awareness Week partner. Privacy Awareness Week is held every year to promote awareness of privacy issues and the importance of the protection of personal information.

Privacy continues to be a hot issue for businesses, government agencies and of course you, our customers. We recognise that our customers value their privacy.  Research has shown that 60 per cent of Australians have decided not to deal with a private business and 25 per cent have decided not to deal with a government agency due to concerns as to how their personal information will be used.

New Australian privacy laws came into force on 12 March 2014. The changes include a new set of Australian Privacy Principles that regulate how we handle your personal information and new enforcement powers for the Office of the Australian Information Commissioner (or OAIC), the federal Australian Government body responsible for privacy in Australia.

These were the most significant changes to privacy laws in over 25 years, affecting a large section of the community.

One of the aims of the new privacy laws is to ensure that your personal information is managed in an open and transparent way.  We take your privacy very seriously, and we want you to know that we have updated our privacy policy in line with the new requirements.

You can access our privacy policy 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
• how you can make a privacy complaint us.

Of course, we are not the only agency that collects your personal information. Here are some tips to help you protect your own personal information:

• Know your privacy rights
• Read privacy policies and notices
• Always ask why, how and who — this will help you to know how your personal information is going to be used, and if it is going to be given to another agency or organisation
• Only give out as much personal information as you need to — always think before handing your personal information over
• Ask for access to your personal information
• Make sure the information an organisation or agency holds about you is accurate and up to date
• Take steps to protect your online privacy
• Make sure your hard copy records are properly destroyed
• You can 'opt out' of marketing communications if you do not want to receive any further contact of this kind
• Make a privacy complaint if you consider that your personal information has not been handled properly.

A pilot died after the canopy of his aircraft opened, interfering with his attempt to land safely.

A pilot died after the canopy of his aircraft opened, interfering with his attempt to land safely.

On 18 September 2013, the pilot of an amateur-built Lancair Legacy aircraft was taking off from Geraldton Airport in Western Australia. He began the take-off roll with substantial engine power and the aircraft accelerated normally to about halfway along the runway. At this point, however, an observer saw smoke from the main wheels, indicating that the brakes were applied momentarily. At the same time the forward-hinged canopy opened about 15 to 30 cm. The pilot did not reject the takeoff, and instead the aircraft lifted off and climbed to about 100-150 ft above ground level.

The ATSB investigation found that while the canopy had been down during the takeoff, it had inadvertently been left unlatched.

The pilot banked the aircraft to the left and during the turn the canopy opened further so that it was at an estimated angle of 30°. The pilot appeared to be manoeuvring for a landing but the aircraft undershot the approach and the wheels hit a road kerb short of the airport perimeter. The aircraft then collided with the perimeter fence and became entangled as it overturned. Shortly after, an intense fire engulfed the aircraft.

Bystanders tried to extinguish the fire with handheld fire extinguishers and a water truck from a nearby worksite but their efforts had no immediate effect. The pilot was rescued from the wreckage and treated for burns, but later succumbed to his injuries.

The ATSB investigation found that while the canopy had been down during the takeoff, it had inadvertently been left unlatched. During his manoeuvring for landing, the pilot had likely encountered control, performance and forward visibility difficulties from the open canopy, affecting the capacity to conduct a normal approach.

The ATSB advises owners, operators and pilots of aircraft with canopies to review the adequacy of their current measures that are intended to ensure canopies are securely latched before flight (such as pre-take-off checks and warning systems), and the actions in case of inadvertent canopy opening during takeoff.

From the momentary brake application when the canopy came open it appears that the pilot’s initial reaction, perhaps instinctive, was to reject the takeoff. However, engine power was not reduced and the takeoff was continued. The decision to stop or go when an aircraft is close to lifting off can be a difficult one. The ATSB advises that, where possible in abnormal situations, pilots should take time to assess the nature of the abnormality to rectify the situation or mitigate the effects.

Read the final report: Canopy-related landing accident involving Lancair Legacy, VH-ALP, Geraldton Airport, Western Australia, on 18 September 2013

The wingtip and aileron separated before the aircraft impacted terrain, fatally injuring the pilot and passenger.

At about 1200 on 15 September 2013, the pilot-owner of a Cessna 206, registered VH-WAV, landed on a public road to repair a truck at a work camp. At about 1516, during take-off from a different, curved road, the aircraft’s left wing struck a tree at a height of about 30 ft. The wingtip and aileron separated before the aircraft impacted terrain, fatally injuring the pilot and passenger. The aircraft was destroyed.

The distance available from where the pilot increased power for take-off was much shorter than the distance advised in the aircraft’s pilot operating handbook under the prevailing conditions.

The accident highlights the importance of carefully considering all relevant factors that could affect the suitability of a particular landing and take-off area.

There was no apparent reason for the pilot to attempt a take-off from that location when a more suitable location was nearby. It is most likely that the pilot misjudged the distance available, the prevailing conditions and their effect on the aircraft’s performance, or had a false recollection of the relative layout of the two roads and thought that there was more take-off room available beyond the curve. However, it is also possible that the pilot’s judgement of the available distance, or his decision-making capability, was affected by a serious medical condition and/or prescribed medications that had not been reported to the Civil Aviation Safety Authority (CASA) until after the pilot’s previous medical certificate had expired.

In addition, the ATSB found that the pilot’s seat had broken from its mounts, probably as the result of heavy, unsecured cargo striking it during the accident sequence. This could have had a detrimental effect on the survivability of the accident.

The accident highlights the importance of carefully considering all relevant factors that could affect the suitability of a particular landing and take-off area. These include: aircraft weight and engine power; wind direction, speed and gusts; ambient air pressure and temperature; surface slope, material, and condition; other physical characteristics of the area such as its length and width; and the height and location of surrounding obstacles.

Though no link with the accident was established, flying without a valid medical certificate, or omitting to report a diagnosed condition or treatment to a Designated Aviation Medical Examiner or to CASA, can lead to such an impairment being undetected or its effect underestimated.

Unrestrained cargo poses a significant risk to the survivability of aircraft occupants. Pilots should take care to ensure that all cargo is adequately restrained to prevent movement during flight and improve survivability in the event of an accident.

Read the final report: Collision with terrain involving Cessna 206, VH-WAV, 156 km south-south-east of Croydon, Queensland, on 15 September 2013

Additional reading: SafetyWatch - General Aviation

During the climb out the aircraft collided with a ferris wheel that was part of a group of amusements located at a beach festival.

The pilot of a Morgan Aero Works Cheetah Sierra 200 aircraft (Sierra), was attempting to land at the Old Bar Airstrip after conducting a private flight from Taree Airport, New South Wales.

The pilot commenced a go-around after touching down. During the climb out the aircraft collided with a ferris wheel that was part of a group of amusements located at a beach festival, adjacent and to the south of the airstrip.

There were two persons on board the Sierra and four occupants of the ferris wheel at the time of the collision. There were no reported injuries from the occupants of the ferris wheel, and the passenger in the Sierra reported receiving a minor injury.

The management of risk in aviation requires diligence and structure to be effective. In particular, when aviation activities are part of a public event...

The ATSB found that the management of risk in relation to flight training operations by Recreational Aviation Australia Incorporated (RA-Aus) was adequate; however, it had been circumvented in a number of areas during the training of the pilot. That resulted in a pilot operating in the aviation environment who did not possess the required competencies to exercise the privileges of a private pilot certificate.

The ATSB also found that the approach to the management of risk by the Old Bar Beach Festival Committee, specifically relating to aviation operations at the beach festival, was ineffective and resulted in a level of risk that had the potential to impact on the objectives of the festival.

RA-Aus have taken steps to ensure that the flight training facility that undertook the pilot’s training and its staff are aware of the requirements imposed upon them by the RA-Aus Operations Manual, and that RA-Aus staff at the facility have the required skills and knowledge to carry out flight training operations. The pilot underwent a flight review that established the need for additional training.

The festival and airstrip committees reported that in future the airstrip will be closed and aviation operations suspended when the festival is taking place.

The management of risk in aviation requires diligence and structure to be effective. In particular, when aviation activities are part of a public event the supporting procedures, processes and guidelines need to be carefully developed and applied to manage risk to those choosing to participate in the aviation environment and to others external to the aviation activity.

Read the final report: Collision with ferris wheel involving Cheetah Sierra 200, 24-7634, near Old Bar, New South Wales, on 1 October 2011

The ATSB has just released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 29 covers short, office-based investigations.

The bulletin covers incidents, serious incidents and accidents involving 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 29 of the Bulletin features 10 safety investigations:

Piston aircraft

• Loss of control during landing involving Cessna 182 VH-LMA
• Fuel starvation and forced landing, involving PA-31, VH-OFF
• Runway excursion involving a Beech A36, VH-EUB
• Inflight fire involving a Beech 58, VH-SBS

Helicopters

• Loss of control involving a Robinson R22, VH-HVW
• Ground fire involving a Robinson R44, VH-TZE
• Collision with terrain involving a Bell 206B, VH-BNG
• Fuel exhaustion event involving a Hughes 269C, VH-HAK
• Collision with terrain involving a Robinson R44, VH-UGR
• Hard landing involving a Bell 206B, VH-XJA

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 29

The student pilot indicated he had about 6 hours sleep the night before the accident.

On 11 October 2013, the student pilot of a G-115C2 Grob aircraft, registered VH-ZIV, departed the Merredin aeroplane landing area (ALA) on his first solo flight to the designated training area located near Lake Brown, Western Australia.

After about 1.4 hours the student elected to return to Merredin, tracking via Burracoppin Township. The student was unable to sight Merredin (ALA) and broadcast on the universal communications (UNICOM) frequency indicating that he was unsure of his position. The UNICOM operator gave him directions to locate Merredin.

While pilots conduct a pre-flight inspection of their aircraft to determine airworthiness, this accident highlights the importance of pilots also assessing their own wellbeing.

The student located Merredin and joined the circuit for runway 28. When on short final he determined that he was too high and initiated a go-around. The student commenced a second circuit to runway 28. When on short final, the student reported there was a crosswind with slight windshear, and the glare from the sun was making it increasingly difficult to see the runway. The aircraft touched down heavily and bounced. The student reported that the sun glare made it very difficult to judge the height of the aircraft and he believed that the aircraft had not bounced very high. At about 1700 Western Standard Time the aircraft touched down again on the nose landing gear, which subsequently collapsed. The aircraft slid along the runway and came to a stop. The student pilot was uninjured and the aircraft sustained substantial damage.

The aircraft operator conducted an internal investigation and determined the student’s last meal was at 0600, which consisted of a sandwich and the operator’s flight risk assessment tool (FRAT) for the accident flight was incomplete. If all values for the flight had been entered, the total risk value for the flight would have been in the red area stating ‘No dispatch’.

The student indicated he had about 6 hours sleep the night before the accident as he was finishing his ground school homework and preparing for the next day.

This accident highlights the importance of pilots also assessing their own wellbeing, to determine if they are physically and mentally prepared, and if the operating conditions are suitable for the conduct of the flight. The effect of sun-glare when relying on visual cues is an important consideration for all pilots.

Read the final report: Hard landing involving a Grob G-115C2, VH-ZIV, Merredin (ALA), Western Australia, on 11 October 2013

A new web page featuring de-identified confidential reports on aviation, maritime and rail safety concerns is now available on the ATSB website.

A new web page featuring de-identified confidential reports on aviation, maritime and rail safety concerns is now available on the ATSB website.

The ATSB’s confidential reporting scheme, REPCON, allows people with safety concerns to report them confidentially to the ATSB without fear of being identified. These confidential reports often contain valuable information that can help industry address unsafe procedures, practices or conditions.

Because many important safety concerns are reported to the ATSB through REPCON, it is vital that all of industry is aware of, and can learn from, the reported concerns. To enhance awareness of these safety issues, the ATSB will make this information available through the publication of de-identified confidential reports on its website.

The published information will include details about safety concerns, as well as responses and safety actions taken by relevant organisations or government agencies about the concern.

It’s important to remember that the information published on the new web page is de-identified to protect the identity of the reporter or any third-party individual. REPCON serves to collect information about safety concerns in the aviation, marine and rail industries, to help facilitate safety action and, ultimately, improve transport safety. 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.

If you have any questions about the new web page or REPCON in general, call the REPCON reporting line on 1800 020 505.

• Read de-identified REPCON reports

Aircraft flight recorders are an invaluable tool for investigators in identifying the factors behind an aircraft accident.

Recorders usually comprise two individual boxes: the Cockpit Voice Recorder (CVR) and the Flight Data Recorder (FDR).

Popularly known as ‘black boxes’, these flight recorders are in fact painted orange to help in their recovery following an accident.

Read more about aircraft flight recorders

The ATSB has just released a new aviation bulletin containing 11 investigation reports. The Aviation Short Investigation Bulletin Issue 27 covers short, office-based investigations.

The bulletin covers incidents, serious incidents and accidents involving 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 27 of the Bulletin features 11 safety investigations:

• Aircraft separation issue involving an Ayres S2R, VH-WBK and an unmanned aerial vehicle
• Ground proximity event between Dornier DO228, VH-VJN and a vehicle
• Loss of ground control involving Air Tractor AT-502B, VH-FLH
• Ground proximity event involving a Cessna 208, VH-LNI and a vehicle
• Total power loss involving a Piper PA-28 161, VH-CCQ
• Incorrect configuration involving Beech A36, VH-YEN
• Hard landing involving a Rolladen-Schneider Flugzeugbau LS7-WL, VH-XJJ
• Hard landing involving a Cessna U206G, VH-UFT
• Collision with terrain involving a Grumman G 164A, VH-CCF
• Aircraft proximity event between a Piper PA-34, VH-FOE and a Piper PA-39, VH-MAB
• Wirestrike involving a Robinson R44, VH-HJT

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 27