• The video can be found on the ATSB’s YouTube channel, ATSBinfo(Opens in a new tab/window)

A new ATSB video shows how easily unexpected events can dramatically increase confusion among flight crew while landing the aircraft.

The incident featured in the video is just one in an increasing number of cases where pilots mishandle or mismanage their aircraft when something unexpected happens during the approach to land phase.

ATSB Chief Commissioner, Martin Dolan, said flight crew and operators should be aware of the growing number of safety occurrences, worldwide, during the landing phase.

“When compared to other phases of flight, the approach and landing has a substantially increased workload and risk,” Mr Dolan said. 

“The ATSB has investigated several incidents that occurred during the approach to land and found that poor communication and lack of role clarification were worryingly common.

“As well as showing how easily flight crew can become confused during an unexpected event, the video emphasises the importance of conducting a go-around to ensure a safe outcome.”

The ATSB’s SafetyWatch initiative provides more information on handling the approach to land along with links to related ATSB investigations. 

The video can be found on the ATSB’s YouTube channel, ATSBinfo(Opens in a new tab/window).

A fatal helicopter accident on a mountain peak left two dead and one seriously injured.

A fatal helicopter accident on a mountain peak left two dead and one seriously injured.

On 8 September 2011, a chartered Eurocopter AS350BA, with a pilot and two passengers on board, was travelling to a helicopter landing site in the Shoalwater Bay military training area in Queensland. The crew were assisting in maintenance of landing sites throughout the area.  The site they were visiting was situated atop the south-eastern peak of Double Mountain. Located at an elevation of 2,421 ft, (738 m), the site was surrounded by trees on three sides with a mast and antenna array on the other.

The direction from which the pilot had approached the site was probably with a wind from the right and ... would have been vulnerable to any unexpected turbulence.

The pilot made four passes of the helipad and then, while hovering or moving at a low speed, the helicopter climbed and started to rotate left. The pilot was unable to control the rotation, and the helicopter descended into the trees before colliding in an inverted attitude with the ground. The pilot and front seat passenger were fatally injured, and the rear seat passenger received serious injuries. The helicopter was substantially damaged and there was no fire.

The ATSB’s investigation could not positively establish the reason for the pilot’s loss of control, although it is most likely to have resulted from environmental and operational factors. The direction from which the pilot had approached the site was probably with a wind from the right and, during his inspection of the site, would have been vulnerable to any unexpected turbulence.

It is part of the normal competency training for licenced helicopter pilots to receive instruction in pinnacle and confined area operations. Those skills, however, are degradable and it is vitally important to ensure that pilots’ competency and skills are appropriate to the task to which they are assigned. 

Read the final report: Loss of control involving Eurocopter AS350BA, VH-RDU, 93 km north of Rockhampton, Queensland, on 8 September 2011

A new video highlighting the ongoing safety concerns for maritime workers has been released by the ATSB today. 

The video features the accident of a crew member on board a ship who was tragically killed by an explosion while cutting a used 200 litre drum with an angle grinder.

ATSB Chief Commissioner, Martin Dolan, said the ATSB has investigated several accidents involving unsafe work practices in the maritime industry.

“We continue to investigate maritime accidents that result in serious injury or death following falls from height, crushing and exploding equipment,” Mr Dolan said.

“These accidents could’ve been avoided if the workers had just given some time to think about the risks involved before they started the task.

“The video provides a powerful reminder to all workers of the need to take risk seriously and to make sure the risk is appropriately managed.”

The video, the fourth in the ATSB’s SafetyWatch video series, can be found on the ATSB’s YouTube channel, ATSBinfo(Opens in a new tab/window).

You can find more information about unsafe marine work practices, along with the ATSB’s other top transport safety priorities, on the SafetyWatch web page. 

An amateur-built 1933 Pietenpol Air Camper collided with terrain after the landing gear caught the top wire of an electric fence.

An amateur-built 1933 Pietenpol Air Camper collided with terrain after the landing gear caught the top wire of an electric fence.

The ATSB is warning pilots that when they are not operating from a designated landing area they need to ensure the area is suitable. This comes after an accident that occurred on 19 May 2013 near St Leonards, Tasmania. The pilot was taking a passenger on a scenic flight around Launceston, starting from a paddock behind his home. He had operated the aircraft from the paddock in the past, but not for a few years. A week before the accident, the pilot surveyed the area by car.

On surveying the accident site, the pilot realised that the aircraft’s landing gear had caught the top wire of an electric fence he had not noticed...

The aircraft was operating normally and became airborne at about 35 knots indicated airspeed. The pilot held the aircraft low, aiming to clear a fence at the end of the paddock. Nearing the fence, the pilot heard a loud noise and the nose of the aircraft jolted to the right.

The airspeed quickly decreased, as the pilot attempted to hold the wings level. After initially climbing to about 10 ft, the aircraft impacted the ground, breaking the landing gear. The aircraft skidded on its nose and then pitched over onto its back, breaking the propeller.

Both the pilot and the front seat passenger exited the aircraft without injury. On surveying the accident site, the pilot realised that the aircraft’s landing gear had caught the top wire of an electric fence he had not noticed, located a short distance before the paddock’s main fence.

Pilots need to assess proposed landing areas carefully, especially if they are not using a designated landing area. A thorough survey of the area to be used for take-off and landing should be completed immediately prior to use.

Read the final report: Collision with terrain involving a Pietenpol Air Camper, VH-ARW, 9 km north of Launceston, Tasmania, on 19 May 2013

The ATSB today released a new YouTube video that demonstrates the serious consequences of simple, undetected human error in data calculation and entry.

The video features animation from the 2009 tail strike accident of an Airbus A340 at Melbourne Airport. In that accident, the crew inadvertently entered the take-off weight data into the aircraft’s electronic flight bag to calculate the aircraft’s take-off settings. The error passed through several subsequent checks without detection.

Through its SafetyWatch initiative, the ATSB has identified data input error as a top safety priority requiring heightened attention from the aviation industry. 

While no one is immune from data input errors, risk can be significantly reduced through effective management and systems.

While no one is immune from data input errors, risk can be significantly reduced through effective management and systems. Good communication and independent cross-checks between pilots, effective operating procedures, improved aircraft automation systems and software design, and clear and complete flight documentation will all help prevent or uncover data entry errors.

This video, along with a series of others, can be found on the ATSB YouTube channel(Opens in a new tab/window). 

Two airspace-related events around the same aeroplane landing area have shown the importance of pilots identifying potential hazards on their planned flight routes, and remaining focused on their surroundings.

Both incidents took place at Nagambie, Victoria. The first incident occurred on 3 May 2013, when the pilot of a Cessna 182 was conducting parachute operations over Nagambie. At the same time, the pilot of a Piper PA-28 aircraft was conducting a private flight from Mangalore to Bendigo, Victoria. He planned to fly from Mangalore to the Nagambie Township and then to Bendigo, to avoid a restricted area and parachute operations danger area.

In both occurrences, the pilots were operating on the see-and-avoid principle of air traffic safety.

A Danger Area is one in which dangerous activity (such as skydiving) takes place, so pilots entering that area need to take appropriate precautions. In contrast, restricted areas are areas of airspace into which pilots cannot fly without permission.

After completing the parachute drop, the Cessna conducted a circling descent, joining the base leg of the circuit and making a broadcast on the radio.

When about 6 NM to the west of the Nagambie Township, maintaining 2,500 ft, the pilot of the Piper saw the Cessna above, on descent, flying from left to right. The Piper pilot took action to avoid the Cessna.

As the pilot of the Cessna entered the danger area, at around 2,000 ft, he saw the Piper in his 12 o’clock position taking avoiding action. He banked his aircraft heavily to avoid the Piper. He estimated the aircraft came within 50 ft of each other.

The second incident occurred five days later, when the pilot of a Bell 206 helicopter was conducting a private flight from Mangalore to Echuca, Victoria, flying via the Nagambie Township to avoid the restricted area, maintaining 1,000 ft.

After passing near the Nagambie Lakes area, the pilot received a call on the radio from the drop zone safety officer on the ground at Nagambie advising that he had just flown over a parachuting landing area. At that time, five parachutists had just landed and six were still airborne.

In both occurrences, the pilots were operating on the see-and-avoid principle of air traffic safety. An ATSB research report, Limitations of the See-and-Avoid Principle, examines the potential risks that can arise in these scenarios.

Read the final report: Two airspace related events, at Nagambie (ALA), Victoria, on 3 and 8 May 2013

The ATSB has completed its safety review of the interstate rail line between Melbourne and Sydney, identifying underlying issues and evaluating the response of the operator.

In 2007, the Australian Rail Track Corporation (ARTC) embarked on a major investment program to upgrade the rail track between Melbourne and Sydney. Since the program began, there have been a number of incidents and the condition of the line has attracted adverse comment regarding its safety, mostly in relation to rough rides and the development of mud-holes. 

On 16 August 2011, the Hon Anthony Albanese MP, Minister for Infrastructure and Transport, requested that the ATSB undertake an investigation to examine the safety of the line’s operations. 

While the treatments applied to date are likely to correct most ballast and drainage problems, the treatments are unlikely to correct the more deep-seated formation problems.

Among various issues, the ATSB investigation found that the track structure between Melbourne and Sydney had historically been particularly vulnerable to degradation in vertical alignment, resulting in the mud-holes and poor ride quality. While this was the result of a number of factors, major contributors were ballast fouling (contamination of the aggregate material laid between the formation and the rails and sleepers) and the weakness of the track formation (the earthwork foundation on which the track was laid).

In some locations, the track upgrade has increased this pre-existing vulnerability as a result of the process of installing new concrete sleepers. 

The track deterioration following the re-sleepering works has required both short-term management and the development of a longer-term major rectification program to maintain the operational effectiveness of the track. Until that rectification takes place, the safety of train operations has been maintained largely through the application of speed restrictions. These speed restrictions, together with increased maintenance activities, have resulted in extended train running times along the corridor.

While the treatments applied to date are likely to correct most ballast and drainage problems, the treatments are unlikely to correct the more deep-seated formation problems. Unless additional treatments are applied to improve the formation, it is possible that water will continue to weaken the structure in some locations. That would, in turn, require an increased regime of track maintenance (or some localised formation reconstruction) and the application of new or further speed restrictions.

The ATSB is satisfied that, taken as a whole, the necessary steps have been taken to address any issues that might otherwise compromise the safety of rail operations on the Melbourne to Sydney line where track quality is below acceptable operational standards. However, the actions taken to ensure safe operations have come at the expense of operational efficiencies through increased train running times.

Read the report: Investigation of rail operations on the interstate rail line between Melbourne and Sydney

The main engine of the bulk carrier ID Integrity shut down and could not be restarted, leaving the ship drifting across the Coral Sea.

The main engine of the bulk carrier ID Integrity shut down and could not be restarted, leaving the ship drifting across the Coral Sea.

The ATSB is warning ship operators of the importance of heeding service advice from machinery manufacturers, and of maintaining all associated documentation. This reminder comes after a serious incident in the Coral Sea.

On 18 May 2012, ID Integrity was sailing from Shanghai, bound for Townsville, where it was going to load a cargo of sugar. While transiting the Coral Sea in heavy seas, the ship’s main engine shut down after its fuel pump reversing mechanism came free and jammed. This caused the camshaft to bend and slip in a drive coupling which resulted in the camshaft being out of timing and the engine unable to be restarted.

The ship’s master reported the situation to the Rescue Coordination Centre. The ship was in no immediate danger (about 100 miles to the east of Osprey Reef) and the engineers searched for the cause of the main engine stoppage. In the meantime, the ship’s managers negotiated a commercial towage agreement, and two tugs were dispatched to assist ID Integrity.

For around 52 hours, the ship drifted in a westerly direction towards the Australian coast and the Great Barrier Reef. Driven by the currents and the tides, it travelled more than 150 nautical miles. 

As ID Integrity approached Shark Reef, it became apparent that none of the tugs would reach the ship before it was likely to pass over the Reef. Other contingencies, including the use of the ship’s anchors, were considered. It was agreed that the master would de-ballast the ship to reduce its aft draught to 5.0 m, increasing the ship’s under keel clearance to the maximum possible. The minimum charted depth for Shark Reef is 8.1 m.

ID Integrity drifted across the southern end of Shark Reef in waters about 20 m deep, about 4 miles south of the charted 8.1 m depth. The ship was now about 60 miles from the eastern edge of the Great Barrier Reef Marine Park and was expected to close on it in less than 24 hours. 

At 0900 on 20 May, the tug PT Kotor rendezvoused with ID Integrity about 35 miles to the east of the Great Barrier Reef Marine Park. In the rough seas, it took about an hour to connect a tow line. The bulk carrier was towed to Cairns for repairs.

The ATSB found that the engine manufacturer had identified the need for owners and operators to check the fuel pump reversing mechanism for cracks and secureness and provided this advice in service letters. However, this advice had not been included in the engine manuals or planned maintenance system on board ID Integrity. As a result, over time and despite regular inspections, the system had deteriorated and cracks had developed in the mechanism undetected. This led to the failure of a fuel pump reversing link on 18 May. 

Read the final report: Breakdown and subsequent drift towards danger of the bulk carrier ID Integrity, Coral Sea, 18 to 23 May 2012

The ATSB is praising the crew of a Beechcraft B58 (Baron) for their handling of a nose landing gear collapse, which resulted in a wheels-up landing, without injury.

The ATSB is praising the crew of a Beechcraft B58 (Baron) for their handling of a nose landing gear collapse, which resulted in a wheels-up landing, without injury. 

The aircraft, with a pilot and co-pilot on board, took off from Hervey Bay bound for Toowoomba, Queensland on 3 April 2013. Shortly after take-off, as the landing gear was being retracted, the crew heard a loud bang. They detected a possible issue with the aircraft’s nose landing gear and began troubleshooting.

After unsuccessful attempts to diagnose the exact problem or to manually extend the nose landing gear, the crew decided to leave it extended and continued to fly to Toowoomba. After flying over the runway at Toowoomba, ground personnel advised the crew that the aircraft’s nose landing gear had extended but was not in the locked position. 

The crew took time to formulate a strategy for their landing, assigning responsibilities to each crew member and then rehearsed their plan.

The crew flew the aircraft to a training area to circle while emergency services were put in place for a wheels-up landing. During the next 45 minutes, they planned and rehearsed their landing in accordance with the aircraft’s flight manual. When advised that emergency services were in place, the crew elected to conduct a larger than normal circuit pattern to gain extra preparation time and so they would not feel rushed.  The crew landed the aircraft in accordance with their plan. As the main landing gear touched down the pilot selected fuel and mixture controls off, while the co-pilot reduced the throttle settings to idle and switched off the electrical system. When lowered, the aircraft’s nose slid along the runway. The aircraft stopped and the crew safely exited. As a precaution, the aircraft was covered with fire retardant foam but there was no fire. 

The aircraft had been built in the United States in 2012, was first registered in Australia on 29 January 2013 and had flown a total of 87 hours. An examination of the aircraft showed that the rod end of the nose landing gear forward retract rod had separated from the plunger tube on the nose landing gear plunger assembly. The examination suggested that there may have been a manufacturing issue. The nose landing gear of a second Baron aircraft built in 2012 with 127 hours service showed signs of a similar defect. 

The manufacturer determined that a required copper braze had not been placed in the plunger tube and this had led to the rod end separating from the plunger tube. It was found that the assembly of the rod-end retract assemblies had been outsourced to an external supplier in 2012. The external supplier had outsourced the brazing process. Eight other assemblies were found to be faulty, and the manufacturer issued a mandatory service bulletin. 

This incident highlights the benefits of flight crew using time to their advantage. The crew took time to formulate a strategy for their landing, assigning responsibilities to each crew member and then rehearsed their plan. This ensured they were well prepared, which ended in a safe outcome. 

Read the final report: Landing gear collapse involving a Hawker Beechcraft G58, VH-OMS, at Toowoomba Airport, Queensland, on 3 April 2013

An aircraft’s radio failure has shown the importance of maintaining communications and the need to alert Air Traffic Control of any problems as soon as possible.

An aircraft’s radio failure has shown the importance of maintaining communications and the need to alert Air Traffic Control of any problems as soon as possible.

On 5 April 2013, a Mitsubishi MU-2B aircraft with two pilots on board departed from Honiara in Solomon Islands, en route to Essendon, Victoria, with an intermediate stop at Townsville. On the way to Townsville, the pilot in command found that the aircraft’s high frequency (HF) radio was not working. Consequently, the crew relayed their aircraft’s position reports to Air Traffic Control (ATC) via other aircraft operating in the area.

As the aircraft drew closer to Townsville, the crew were able to communicate directly with ATC using the very high frequency (VHF) radio. The aircraft landed safely at Townsville and was refuelled. The pilot submitted a flight plan to Airservices Australia providing details on the aircraft’s planned route to Essendon. 

The ATSB emphasises the importance of alerting Air Traffic Control to any problems as soon as possible.

Shortly after take-off from Townsville, however, both the pilots and ATC discovered that the aircraft was transmitting carrier wave only (no voice communications could be heard). Townsville ATC offered the crew the option of returning to Townsville. The pilots could hear the transmissions made by Townsville ATC, but were unable to return as the fuel quantity in each wing tip tank was in excess of the maximum landing limitation and the aircraft was carrying additional fuel in the ferry tank. The pilots could not advise Townsville ATC of this as the aircraft’s very high frequency (VHF) radios were now inoperable. Consequently, the pilot elected to continue the flight as per the submitted flight plan.

The pilot attempted to fix the radio problem, but without success. ATC continued attempts to re-establish communications and left voice and text messages on both pilot’s mobile telephones and utilised two overflying aircraft. The Australian Search and Rescue (AusSAR) were also briefed on the situation. As the journey continued, Townsville ATC, Brisbane Centre ATC and Melbourne Centre ATC also continued attempts to establish communications with the crew.

When about 230 NM north of Essendon, communications with ATC were re-established. The crew had not been in normal communications with ATC for about 3 hours and 35 minutes. The aircraft landed safely.

A subsequent examination of the radio determined that water leakage from a small access door had corroded two main radio isolator breakers/switches, which resulted in the radio failure. The aircraft had been left outside for some time and subjected to tropical storms.

The ATSB emphasises the importance of alerting Air Traffic Control to any problems as soon as possible. This provides ATC with sufficient time to manage a situation, rather than having to react when an issue has developed into a major problem. In the event of a communications failure, it is important that pilots follow the appropriate procedure, and if radio communications cannot be re-established, consider utilising alternative methods such as mobile telephones.

Read the final report: Radio failure involving Mitsubishi MU-2B-60, N64MD, near Townsville Airport, Queensland, on 5 April 2013