The ATSB is urging aircraft owners and registration holders to review their maintenance schedules after a Cessna pilot’s control difficulties were found to be caused by component fractures and cracking.

The ATSB is urging aircraft owners and registration holders to review their maintenance schedules after a Cessna pilot’s control difficulties were found to be caused by component fractures and cracking.

The ATSB is strongly encouraging registration holders of class B aircraft to review their aircraft’s maintenance schedule to determine if it is the most appropriate for their aircraft and to ensure that it adequately provides for the continuing airworthiness for their aircraft.

This warning comes after a 12 September 2011 incident when the pilot of a Cessna 210 aircraft was conducting low-level aerial surveying near Bourke Aerodrome, New South Wales. After briefly encountering turbulence, he had difficulty making elevator control inputs and maintaining height. He was able, however, to land the aircraft safely with no injuries.

The ATSB has issued two safety recommendations to CASA as part of this investigation.

The ATSB investigation found that the control difficulties resulted directly from the fracture of the aircraft’s two horizontal stabiliser rear attachment brackets. The forward spar of the horizontal stabiliser was also extensively cracked. The fractures and cracking were all consistent with metal fatigue and typical of the damage that can be sustained by aircraft as they age. Many manufacturers have addressed the growing potential for this type of damage by introducing supplemental inspections to the principal aircraft maintenance requirements.

Some registration holders of class B aircraft, however, believed that their aircraft were exempt from the manufacturer’s supplemental inspections as long as the aircraft were maintained using the CASA maintenance schedule. This belief sprang from a misinterpretation of the Australian Civil Aviation Regulations 1988 (CAR). The CASA maintenance schedule did not make any specific reference to the incorporation of the manufacturer’s supplemental inspections, but it was a CAR requirement that all aircraft be maintained in accordance with approved maintenance data that, by definition, included those inspections.

The ATSB has issued two safety recommendations to CASA as part of this investigation. The first recommends that CASA proceed with its program of regulatory reform to ensure that all aircraft involved in general aviation operations are maintained using the most appropriate maintenance schedule for the aircraft type. The second is to ensure that the provisions of CAR Schedule 5 are clarified in relation to the incorporation of all relevant supplemental inspections specified for the aircraft type.

Read the final report: Flight control system event involving Cessna 210N, VH-JHF, 48 km west of Bourke Airport, New South Wales, on 12 September 2011

The Australian Transport Safety Bureau is supporting Rail Safety Week, which is being held from 12 to 18 August 2013. In its eighth year, Rail Safety Week is an initiative of the Australasian Rail Industry and aims to raise awareness of safety issues around railway lines.

During the week, the ATSB will highlight the ongoing concerns of safe work on rail. We’ve investigated several accidents that have occurred when maintenance work was being carried out on or near railway tracks. Through our SafetyWatch initiative, we urge industry to give heightened attention to the risks and hazards facing rail workers. 

A new video can be found on the ATSB’s YouTube channel (ATSBinfo)(Opens in a new tab/window) highlighting rail worker safety.

ATSB report into a collision between two road rail vehicles that left one driver trapped and seriously injured while five other people sustained minor injuries.

The Australian Transport Safety Bureau (ATSB) has released its preliminary investigation report into a collision between two road rail vehicles that left one driver trapped and seriously injured while five other people sustained minor injuries.

The accident occurred on 4 June 2013, on the West Coast Wilderness Railway in Tasmania. The road rail vehicles used on the railway are trucks designed to travel on both the road and on train tracks. When they transition from the road, they use front and rear sets of rail guidance wheels, which are lowered when the vehicle is positioned on the track. On the day of the accident the track workers placed the road rail vehicle on the track and were preparing to travel to a worksite near Rinadeena Station when it unexpectedly started to roll backwards. The driver was unable to slow the vehicle, so he and the passenger jumped clear, suffering minor injuries.

The vehicle continued to accelerate, out of control, down the steep slope, heading towards a second road rail vehicle containing four track workers.

The now-unmanned vehicle continued to accelerate, out of control, down the steep slope, heading towards a second road rail vehicle containing four track workers. Two passengers of the second vehicle jumped clear, sustaining minor injuries, but a third passenger and the driver were still inside when the unmanned road rail vehicle collided with theirs, pushing it back about 40 m along the track. The passenger sustained minor injuries, but the driver was trapped and seriously injured in the collision. He was subsequently removed from the vehicle and air lifted to hospital. Both road rail vehicles were extensively damaged.

The preliminary ATSB investigation has found that the first vehicle’s rear road-going tyres were lifted from the track during an inspection of the rear rail guidance wheels. As a result, the braking force provided by them was lost and the vehicle began to roll down the grade. The investigation has also found that West Coast Wilderness Railway had not considered all of the risks associated with operating road rail vehicles on the steep railway and, therefore, had not identified the need for operator specific procedures and training.

While the investigation is ongoing, the ATSB is encouraging all rail organisations that operate road rail equipment to consider the advice in safety alert RISN Number 7/2012 Risk associated with Hirail Operations (issued by the Department of Infrastructure, Energy & Resources, Tasmania).

Read the preliminary report: Collision between two road-rail vehicles near Rinadeena, Tasmania, on 4 June 2013

• Safe work on rail video(Opens in a new tab/window)
• SafetyWatch

The ATSB has today released a new YouTube video highlighting the risks and hazards of working on rail, as part of Rail Safety Week.

The video features animation from a fatal accident where a passenger train collided with an excavator near Newbridge, NSW.

ATSB Chief Commissioner Martin Dolan said safe work on rail is a top priority for the ATSB and is an issue that needs heightened attention from the rail industry.

“The ATSB has investigated several accidents that have occurred when maintenance work was being carried out around railway tracks,” Mr Dolan said. “These accidents were primarily the result of safe working rules and procedures not being correctly implemented.

“We think more can be done to improve the safety of rail workers, particularly in the areas of good work practices, coordination and communication. 

“The accident highlighted on this video provides a powerful reminder of the importance of following rules and procedures.”

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

More information about the ATSB’s top nine transport safety priorities, including safe work on rail.

The ATSB has just released a new aviation bulletin containing nine investigation reports. The Aviation Short Investigation Bulletin Issue 21 covers short, office-based investigations. 

The bulletin covers incidents, serious incidents and accidents involving turboprop and piston aircraft. No one was injured in any of the incidents; however, some of the aircraft were damaged.

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.

The incidents covered in the report include:

• Radio failure involving a Mitsubishi MU-2B, N64MD
• Airspace related event between Bombardier DHC-8-402, VH-QOB and Robinson R22, VH-HLY
• ATC procedural error involving a Piper PA-34, VH-FEJ
• Aircraft proximity event between a Kawasaki BK117, VH-CSG and a Cessna 404, VH-XDA
• Nose landing gear malfunction involving a Hawker Beechcraft B58, VH-OMS
• Aircraft proximity event between Piper Chieftain, VH-EDV and Cessna 172 Hawk XP, VH-JQQ
• Aircraft proximity event between a Mooney M20, VH-FRO and a Piper PA-31, VH-HJE
• Two airspace related events at Nagambie (ALA)
• Collision with terrain involving a Pietenpol Air Camper, VH-ARW

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 21

The Transportation Safety Board of Canada (TSB) will conduct an independent external review of the ATSB’s investigation processes and publish the results. The review was announced today by TSB Chair, Wendy A. Tadros and ATSB Chief Commissioner, Martin Dolan. 

The review, to begin with an initial visit by the TSB team this month, will provide an independent and objective assessment of the ATSB’s investigation methodology and processes. 

The review team will benchmark TSB investigation methodologies with the ATSB’s and compare them with international standards. The review will also examine how ATSB methodologies and processes have been applied to ATSB investigations and compare them with TSB approaches. 

Mr Dolan said the review is a new step in the ATSB’s continuing close cooperation with other international investigation agencies. It will provide both organisations with a significant learning opportunity.

“I invited the TSB to conduct the review because we are always looking to improve our investigation systems and approaches,” Mr Dolan said. “I’m grateful that our Canadian colleagues have agreed”.

“The review will identify best practices from both organisations that we can adopt to improve how we investigate accidents and occurrences and improve transport safety.

“The TSB is well placed to conduct this review as they have a similar legislative framework to the ATSB and a long-standing commitment to systemic investigation to improve safety.”

It is anticipated that the TSB will produce a final report early in the northern spring of 2014. The report will be published by the TSB and available on the TSB website. 

Any questions about the TSB review should be directed to the ATSB on 1800 020 616.

The ATSB has just released the first in a series of short YouTube videos highlighting areas where more can be done to improve transport safety in Australia. 

The first video focuses on the recurring dangers facing general aviation pilots, particularly around low-level flying, striking power lines, fuel management and flying into bad weather.

ATSB Chief Commissioner, Martin Dolan, said the videos are part of the ATSB’s efforts to increase awareness of the recurrent risks that need to be managed in the aviation, maritime and rail communities. 

The ATSB will release eight videos 
over the coming weeks.

“We’re finding through our investigations that many accidents, even fatal ones, are avoidable through better planning and execution,” Mr Dolan said.

“We’ve produced these videos to help the transport industry give heightened attention to these areas of safety concern. 

“The videos contain case studies of accidents and incidents along with advice from the ATSB’s own investigators. They send a powerful message from the people who are in the best position to understand the consequences when things go wrong.”

The ATSB will release eight videos over the coming weeks. The other topics that will feature in the series include safe work on rail, safety around non-towered aerodromes, maritime pilotage, data input errors, handling approach to land, under reporting of occurrences, and marine work practices.  

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

More information about these top safety concerns is available on the ATSB’s SafetyWatch page. 

The ATSB is cautioning helicopter pilots about the dangers of ‘loss of tail rotor effectiveness’ following the forced landing and crash of a Bell 206B3 helicopter in Perth earlier this year.

The ATSB is cautioning helicopter pilots about the dangers of ‘loss of tail rotor effectiveness’ following the forced landing and crash of a Bell 206B3 helicopter in Perth earlier this year. 

The accident occurred on 19 January 2013, while the helicopter was being used on an aerial filming task over hilly terrain. 

After hovering and manoeuvring at about 500 ft above the ground to allow the camera operator to record footage of a truck accident, the pilot conducted a final circuit to complete filming and depart the area. The pilot began the turn when the nose of the aircraft moved left, then suddenly and rapidly to the right as the helicopter yawed and quickly rotated five times.

The pilot regained some control close to the ground, but judged that a forced landing was inevitable. In an area with a number of obstacles, the pilot selected a clearing and managed to perform a low-impact landing. The slope that he landed on, however, resulted in the helicopter immediately rolling over with the engine still operating. Fortunately, it did not catch fire, a factor that can make all the difference for the survival of occupants in such accidents.

As well as understanding how LTE can occur, pilots should be familiar with the recommended recovery techniques and apply them immediately to the fullest extent possible in the situation.

The ATSB investigation found that when the pilot turned to the right to commence the circuit, the helicopter was exposed to a crosswind from the left while operating at an airspeed that left it susceptible to loss of tail rotor effectiveness (LTE) — a phenomenon which can send a helicopter moving in unexpected directions while temporarily robbing the pilot of control.

Aerial photography from most helicopters at relatively low airspeed and height, over hilly terrain in variable winds, is a challenging task with an inherent risk of LTE. In those circumstances, where visual cues can be misleading, pilot attention to airspeed, height and orientation to local wind is critically important. And, as in this occurrence, LTE can be preceded by momentary strong yaw in the opposite direction—a characteristic which is counter-intuitive and has the potential to be confusing for the pilot. There are recommended techniques for recovering from LTE.

The helicopter operator advised that as a result of the accident they conducted an internal investigation and implemented a number of safety actions in relation to LTE training and aerial work guidelines.

Read the final report: Loss of control and forced landing involving Bell 206B3 helicopter, VH-ZMN, 18 km north-east of Perth Airport, Western Australia, on 19 January 2013

A new ATSB report reveals that there is no significant difference in competency and proficiency of low-hour airline pilots who undertake cadet pathway programs when compared with their direct entry and high-hour peers.

The issue of pilot cadet pilot training programs has been the subject of significant debate and concern within the aviation industry. Cadets are pilots who, generally, have received limited or no prior flight training before starting their cadetship. Instead, they are trained specifically for an airline at a flight training organisation. After training, these pilots enter the airline as a second or first officer, depending on the airline and its requirements. 

These pilots, with their comparatively low hours of experience, are sometimes perceived to be less competent than those who have taken more traditional routes. Traditional routes involve the accumulation of flight hours either with the Defence Force, in general aviation or other (often smaller) airlines, before the pilots enter a major airline as a second or first officer. 

The research revealed that overall performance of cadets and low-hour pilots matched that of their direct entry and high-hour peers.

This issue was highlighted after two high-profile international aviation accidents in 2009, one involving a Bombardier DHC-8 at Buffalo, New York, and the other, an Airbus A330 operating as Air France flight 447 (AF447), en-route from Rio de Janeiro, Brazil to Paris, France. In response to the DHC-8 accident, the United States Congress enacted legislation to increase the amount of flying experience that first officers would need, in order to enter an airline, to 1,500 hours.

Despite the debate and regulations, there has been very little research on the differences between pilots with different training backgrounds. For the research report, Pilot experience and performance in an airline environment, the ATSB gathered data from three airlines to explore the issue of pilot performance as a function of both flight hour experience, and entry pathway. Entry pathway analysis compared cadet pilots (who generally had not accumulated prior flight hours or experience) to those pilots who entered an airline after accumulating flight hours in other areas of the aviation industry.

The research revealed that overall performance of cadets and low-hour pilots matched that of their direct entry and high-hour peers. All pilots were marked as proficient at the completion of the check flights, with the only differences between the groups being a function of how many exceeded the required standard.

The evidence in this report indicates that despite industry concerns, the cadet pathway for low-hour pilots is a valid option for airlines. There was no evidence to suggest that cadets or low-hour pilots within the airlines studied were any less competent or proficient than their direct entry and high-hour peers.

Read the full research report, Pilot experience and performance in an airline environment AR-2012-023.

On 7 January 2013, a Piper PA-28 aircraft with a student pilot on board lost a wheel during take-off at Mangalore Airport.

On 7 January 2013, a Piper PA-28 aircraft with a student pilot on board lost a wheel during take-off at Mangalore Airport.

After take-off an instructor on the ground noticed something trailing the aircraft and radioed the pilot to make a low-level pass so they could determine what the object was.

Following the low-level pass, the instructor noticed that the right main wheel and inner cylinder of the landing gear assembly had detached from the upper cylinder and was hanging off the brake line. After a second low-level pass they were seen to have detached completely.  

The aircraft touched down on the runway and slid off to the side, coming to rest on grass.

The instructor advised the student to hold over the airfield to burn off fuel and allow time for a plan to be devised. After several hours and with emergency services in attendance the student was instructed to make a normal approach. The aircraft touched down on the runway and slid off to the side, coming to rest on grass. The student was uninjured, but the aircraft was extensively damaged. 

An engineering examination revealed the lower torque link attachment bolt had failed via bending fatigue due to asymmetric loading (bending from one side). In September 2011, CASA had issued an Airworthiness Directive requiring inspection of torque links on all PA-28 aircraft every 100 hours, consistent with Piper Service Letter No 1199 and replacement with a new style link at 5000 hours. The aircraft had been fitted with the new style links; but there had been no requirement to inspect the torque link attachment bolts.

The operator has undertaken to replace all torque link attachment bolts during the next scheduled maintenance on all their Piper PA-28 aircraft. They will also treat any landings where a sideways load on the wheel assembly may have occurred with caution.

Read the final report: Landing gear separation involving Piper PA28, VH-JXR, Mangalore Airport, Victoria, on 7 January 2013