An incident on 30 January 2013 involving a Fairchild Metro aircraft, flying freight from Melbourne to Launceston highlights the importance of correctly loading freight aircraft.

An incident on 30 January 2013 involving a Fairchild Metro aircraft, flying freight from Melbourne to Launceston highlights the importance of correctly loading freight aircraft.

Before the flight, the pilot conducted his flight planning away from the aircraft and prepared a trim sheet to confirm the weight and balance information (The trim sheet or loading plan contains directions to the loaders to ensure that freight is correctly distributed on the aircraft so that it can remain within the centre of gravity range while in flight.) He supplied this to the freight company that prepared a loading plan for the aircraft.  When the pilot arrived at the aircraft the freight had been loaded, all cargo access doors had been closed and the cargo support strut (tail stand) had been removed. The pilot completed pre-flight checks and removed the wheel chocks and wing tip safety markers, before taking off.

While taking off, the pilot experienced difficulty achieving the correct trim. During the flight the auto-pilot struggled to maintain straight and level flight resulting in the aircraft ‘porpoising.’

While taking off, the pilot experienced difficulty achieving the correct trim. During the flight the auto-pilot struggled to maintain straight and level flight resulting in the aircraft ‘porpoising.’ The pilot conducted a normal landing in Launceston.

After landing, the pilot investigated the freight loaded in the nose of the aircraft and discovered that the locker only contained 35 kg of freight when it should have contained about 100 kg. The loading plan had indicated that there should be 100 kg in the nose locker but one of the loaders had removed about 70 kg and placed the cargo in the rear of the aircraft. This resulted in a rearward centre of gravity during the flight.

After investigating this incident, the operator found that:

• freight transferred from other flights had not been re-weighed,
• marked weight on freight pallets did not indicate whether it was gross or net
• the supervisor and ground personnel were not trained in loading procedures for the aircraft
• there was no strict control on the weight being loaded into each zone of the aircraft
• loaders were estimating freight weights going into each zone
• there were no procedures available for where to load cargo when the zone could no longer fit the cargo allocated to it.

As a result of this incident, the aircraft operator took action to issue a safety alert to all pilots requiring them to remove the cargo support strut and check the aircraft is loaded in accordance with the loading plan. They also undertook extensive improvements to documentation, training, audit, risk management, change management and project plans to improve ground handling and organisational safety.

Read the final report: Weight and balance event involving Fairchild SA-227AC, VH-UUO, Melbourne Airport, Victoria, on 30 January 2013

The ATSB has released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 20 covers short, office-based investigations. 

The bulletin covers incidents, serious incidents and accidents involving turboprop, piston aircraft and helicopters. Only one of the incidents involved injury, however, some of the aircraft suffered substantial damage.

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:

• Weight and balance event involving Fairchild SA-227AC, VH-UUO
• Landing gear separation involving Piper PA28, VH-JXR
• Wheels up landing involving Cessna 210M, VH-PBV
• Collision with terrain involving Grob G-115, VH-ZTM
• Aircraft proximity event between a Piper PA-44, VH-TYS and a Cessna 172S, VH-EUH
• Landing gear collapse involving Piper PA-30, VH-HPR
• Wheels up landing involving Piper PA-24-260, VH-DRB
• Weather related precautionary landing involving a Piper a PA-28, VH-MSG
• Collision with terrain, involving AS350, VH-EWM
• Wirestrike involving Enstrom 480B, VH-VDC

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 20

The ATSB today released the final report of its investigation into the uncontained engine failure involving a Qantas Airbus A380 over Batam Island, Indonesia on 4 November 2010. 

The accident occurred shortly after the aircraft took off from Singapore. At about 7,000 ft above Batam Island, one of the aircraft’s Rolls-Royce Trent 900 engines failed, sending debris into the aircraft’s left wing and fuselage, and onto Batam Island. There was significant damage to the aircraft’s electrical, hydraulic and other systems. The crew managed the multitude of system failures before safely returning and landing the aircraft.

The ATSB found that the engine failure was the result of a fatigue crack in an oil feed pipe. The crack allowed the release of oil that resulted in an internal oil fire. The oil fire led to one of the engine’s turbine discs separating from the drive shaft. The disc then over-accelerated and broke apart, bursting through the engine casing and releasing other high energy debris.

The ATSB also found that the oil pipe, together with a number of similar pipes in other engines, had been made with a thin wall section and did not comply with the design specifications. The thin wall substantially increased the likelihood of fatigue cracking.

This investigation has been one of the more complex undertaken by the ATSB in recent years and has involved a large commitment of resources. As well as understanding how the engine failed, the investigation had to review why quality assurance did not adequately manage the oil pipe problem and what were the implications of the damage to the aircraft.

The ATSB worked closely with international regulators, Rolls-Royce and Airbus to ensure the continued safety of Trent 900-powered A380s. Early in the investigation, the ATSB issued a recommendation to Rolls-Royce about the manufacture of the oil feed stub pipes. As part of its final report, the ATSB issued recommendations to the European and US regulators so that lessons learned from this accident would be incorporated into aircraft certification advisory material designed to minimise hazards from uncontained engine failures.

As a result of the ATSB’s investigation, regulatory authorities and operators around the world took steps to ensure that engines with non-conforming oil feed stub pipes were identified and managed appropriately. Rolls-Royce also made changes to their quality assurance system to improve the way they manage non-conforming parts. 

Read the final report: In-flight uncontained engine failure Airbus A380-842, VH-OQA, overhead Batam Island, Indonesia, on 4 November 2010

A Cessna 210M’s wheels-up landing at Broome shows how bad weather and changed plans can distract a pilot from flying safely, according to an ATSB investigation report.

A Cessna 210M’s wheels-up landing at Broome shows how bad weather and changed plans can distract a pilot from flying safely, according to an ATSB investigation report.

On 23 February 2013, the Cessna was returning to Broome airport with a pilot and four passengers on board. The conditions were windy and wet with thunderstorms and rain moving through the area.  This meant the pilot had to alter the flight plan and flight path to avoid the poor weather.

While preparing for landing, the pilot reported selecting the landing gear down as part of his landing checks. A passenger later reported hearing what he believed to be the landing gear being lowered.

The aircraft landed on the runway with its landing gear retracted and skidded about 300 to 350 m on its underbelly.

Shortly before landing the pilot completed his final checks but did not look out the window to visually check that the landing gear was down. He reported, however, that he saw a green light that indicated the landing gear was down.

The aircraft landed on the runway with its landing gear retracted and skidded about 300 to 350 m on its underbelly. The pilot reported that the landing gear warning horn had not activated.

An insurance assessor found that the pilot had not extended the landing gear before landing and noted that the micro switch that activated the landing gear warning horn was set for a lower throttle setting than was used by the pilot. To compensate for the strong crosswind, the pilot operated the aircraft at a slightly higher throttle while coming into land.

An accident investigation report(Opens in a new tab/window) produced by the United Kingdom Air Accidents Investigation Branch provides further information on the link between the throttle settings and the activation of the gear warning horn on the Cessna 210.

Read the final report: Collapsed landing gear involving Cessna 210M, VH-PBV, at Broome Airport, Western Australia, on 23 February 2013

The crash of a Cessna 150 due to a stall is a reminder that pilots should take every opportunity to refresh their knowledge and skills.

The crash of a Cessna 150 due to a stall is a reminder that pilots should take every opportunity to refresh their knowledge and skills. 

On the morning of 29 April 2012, the owner-pilot of a Cessna 150 was aerial stock mustering on a cattle station near Bourke, New South Wales. Some patches of fog had cleared, and the weather was fine and calm. 

After about 1.5 hours in the air, the pilot radioed stockmen on the ground to direct them to an area where cattle were not moving. The aircraft was seen circling over the area at about 100 ft and a short time later, in a steep descent towards the ground. The pilot died in the accident. 

The ATSB found that while manoeuvring at low level the pilot had inadvertently allowed the aircraft to aerodynamically stall, resulting in a high rate of descent and collision with the ground. 

The pilot did not hold a valid medical certificate and had not completed a flight review for a number of years. These both increased the risk of operating an aircraft, especially during aerial mustering operations. 

The accident highlights the importance of pilots undergoing a flight review at least every 2 years and practicing routine procedures under the supervision of instructors or approved training/check pilots.

Read the final report: Collision with terrain involving Cessna 150, VH-UWR, 55 km north-east of Bourke, New South Wales, on 29 April 2012

An accident involving a Cessna that struck a tree and overturned during take-off shows why it’s vital for pilots to know how the performance limits of their aircraft.

An accident involving a Cessna that struck a tree and overturned during take-off shows why it’s vital for pilots to know how the performance limits of their aircraft.

On 9 February 2013, the Cessna 150F was taking off on the 11th fairway of the Mt Broughton Golf Course, NSW. The pilot had permission to land on the golf course and said he had previously landed and taken off there without incident. 

The pilot reported that the aircraft accelerated as normal, but when he realised it would not clear the trees at the end of the landing area, he elected to reject the take-off. The pilot reduced power and applied the brakes but ran out of clear space before the Cessna’s left wing hit a tree. The aircraft turned over and came to rest upside down. The pilot was uninjured, but the aircraft was badly damaged. 

The accident highlights the importance of pilots following the published performance data for their aircraft and knowing the performance requirements...

The pilot stated that the landing area had short grass that was wet with dew. He said that the aircraft had been fitted with a more powerful 160 horsepower engine (instead of the original 100 horsepower) and he did not know the available take-off distance at Mt Broughton.

An insurance assessor subsequently investigated the accident site and determined that the take-off length of the landing area was 1,180 feet. The performance charts for a standard Cessna 150F required 1,583 ft, however there was no available performance data for the 160 hp engine. 

The accident highlights the importance of pilots following the published performance data for their aircraft and knowing the performance requirements, physical characteristics and dimensions of the landing area that they intend to use. Other factors such as environmental conditions also need to be taken into account. 

Read the final report: Collision on ground involving a Cessna 150F aircraft, VH-ICE, 21 km south-west of Mittagong (ALA), New South Wales, on 9 February 2013

An accident where a radio failure prevented one pilot from warning another of a runway hazard highlights the importance of reliable communications.

An accident where a radio failure prevented one pilot from warning another of a runway hazard highlights the importance of reliable communications.

On 22 February 2013, two Dromader aircraft were spraying cotton crops at Rumleigh (7km east-south-east of Brewarrina), NSW. One of the aircraft (TGY) was in the air while the other (TZJ) was being loaded with chemicals. TZY was about to take-off when its firebombing door unexpectedly released and spilled a large quantity of the chemical on the ground, contaminating the runway. (A firebombing door is attached to the aircraft’s hopper and enables a load to be released very quickly when it is used for fire suppression operations.)

The contamination created a layer of mud, which was not easily visible from the air. The pilot of TZJ tried unsuccessfully to contact TGY’s pilot to warn him of the hazard. The radio in TZJ had been working only intermittently since the previous day and had failed completely, so the broadcasts were not heard.

On landing, TGY crossed the contaminated area with one of its wheels and the mud caused it to slide and swing to the left. Eventually it pitched forward, and the propeller struck the ground. The pilot was not injured, and the aircraft sustained minor damage.

The pilot of TGY commented that it would be normal when they were unable to contact someone by UHF radio to send a text message by mobile phone or to place the mixers’ truck on the runway to provide an alert.

Having a reliable communications system or agreeing an alternative method of warning pilots of potential ground hazards will improve the efficiency and safety of an operation.

Read the final report: Loss of ground control involving a PZL-Mielec M18A Dromader, VH-TGY, 7 km east-south-east of Brewarrina (Rumleigh), New South Wales, on 22 February 2013

A passenger jet took off at night without the crew noticing that the runway lights were off.

An incident where a passenger jet took off at night without the crew noticing that the runway lights were off has illustrated the tricks that our minds can play on us.

At 11.27pm on 14 December 2012, the flight crew of a Jetstar Airbus A320 was preparing for take-off at Hobart Airport.

Outside tower hours, Hobart Airport operated as a non-towered, uncontrolled airport, operating on a common traffic advisory frequency. During that time, pilots could use radio transmissions to turn on the runway lights themselves.

As the flight crew prepared for take-off, they were under the impression that the runway lights were already on. The aircraft had several external lights, which illuminated the ground in front of the aircraft, and the Captain and First Officer saw several indicators that they took to mean that the lights were on. Both flight crew later commented that they had no difficulties maintaining directional control during the taxi and take-off roll, further noting that at no time did anything seem unusual or out of the ordinary.

...expectation bias is ‘seeing’ what you expect to see even when it is not there — in this case, runway lighting being on.

Runway and taxiway lighting serves many important functions for a departing aircraft. It can show the end of the runway, as well as necessary guidance for approach and landing if an emergency arises shortly after take-off. While the aircraft took off safely on this occasion, the incident highlights the potential hazards associated with change blindness, inattention blindness and expectation bias.

Change blindness occurs when a person does not notice that something is different about the visual environment relative to before the change. Research has shown that in some cases, quite dramatic changes are not detected, particularly if changes occur when the observer is not looking at the relevant part of the visual environment.

Inattention blindness occurs when a person does not notice an object which is visible, but unexpected, because their attention is engaged on another task. In this instance, the absence of airport lighting was noticeable, if looked for. However, the crew had an assumption or expectation that the lighting was on.

In simple terms, expectation bias is ‘seeing’ what you expect to see even when it is not there— in this case, runway lighting being on.

As a result of this occurrence, Jetstar Airways and Hobart International Airport have both taken action to ensure there is not a repeat of this incident.

Read the final report: Runway event involving Airbus A320, VH-JQG, at Hobart Airport, Tasmania, on 14 December 2012

Following a stevedoring fatality, the ATSB has issued two safety advisory notices to stevedoring companies, highlighting the risks of break-bulk cargo toppling and of stevedore fatigue.

Following a stevedoring fatality, the ATSB has issued two safety advisory notices to stevedoring companies, highlighting the risks of break-bulk cargo toppling and of stevedore fatigue.

On 23 September 2012, a team of stevedores was loading aluminium ingots in the cargo holds of the general cargo ship Weaver Arrow, which was berthed in Newcastle, NSW. The ingots, each weighing about 23 kg, were strapped into 1-ton ‘packs’ of 44. Multiple packs (20 or 24) were strapped together to form a cargo unit or lift. 

The stevedore team leader was climbing down the ingot packs of a lift to work on a lower tier of the cargo when another member of the team saw the stack move. He yelled a warning, urging the team leader to jump. As the packs he was climbing down toppled, the team leader either jumped or fell to get clear. However, the adjacent stacks also toppled over in quick succession and packs from those crushed the team leader.

Other stevedores raised the alarm and tried to help the crushed man but he showed no signs of life. Paramedics and police officers arrived on the scene shortly afterwards and confirmed that the stevedore was dead.

No work should be undertaken in the vicinity of ingot stacks unless they have been secured
to prevent toppling.

The ATSB investigation found that it was common for some stevedores to climb up or down ingot packs to work on different cargo tiers instead of using the ladders provided. This was despite the fact that the ingot cargo units or lifts were inherently unstable and prone to toppling over. The stevedoring company’s procedure for loading aluminium products did not adequately address the risk of the cargo toppling over, and the implementation of basic precautions, such as using ladders to climb between cargo tiers, was not effectively monitored or enforced.

The ATSB also found that stevedores often worked extended hours, exposing the company’s operations to a level of fatigue-related risk that had not been assessed and treated.

In response, the stevedoring company, the company responsible for preparing ingot packs for loading, and the company managing Weaver Arrow have taken steps to make cargo handling—ingots in particular—safer. The ATSB has promulgated a safety message to industry that individual stacks of aluminium ingots and other similar break-bulk cargoes (whether or not strapped together for carriage on ships) should always be considered unstable and prone to toppling over. No work should be undertaken in the vicinity of ingot stacks unless they have been secured to prevent toppling. The ATSB has also recommended that Newcastle Stevedores address the issue of stevedore fatigue.

Unsafe marine work practices are a continuing concern in Australia. The ATSB has investigated several maritime accidents over the past few years that have resulted in serious injury or death. Through its SafetyWatch initiative, the ATSB is urging the maritime industry to give heightened attention to the ongoing safety issues facing marine workers.   

Read the final report: Stevedore fatality on board the general cargo ship Weaver Arrow, at Newcastle, New South Wales, on 23 September 2012

A crash landing following engine power loss shows why it’s important for pilots to maintain critical skills through regular flight reviews

A crash landing following engine power loss shows why it’s important for pilots to maintain critical skills through regular flight reviews.

On the morning of 23 November 2012, the pilot of a Piper Cherokee Six, with two other owner-pilots on board, took off from Jandakot Airport, Western Australia.

About 700 ft above the ground, the engine suddenly lost power. The pilot immediately turned the aircraft towards one of the runways and focussed on flying the aircraft while the owner-pilot in the copilot seat conducted some of the troubleshooting checks. Unfortunately, the engine did not regain power.

The pilot had not completed a flight review in the 2 years before the accident, increasing the operational risks including responding to emergency situations.

Without enough height and speed to reach the runway, the pilot force landed the aircraft into wooded bushland about 150m short of the runway. The aircraft’s occupants escaped the accident with only one minor injury, but the aircraft was substantially damaged after hitting trees.

While the ATSB found no mechanical defects or fuel issues that would have affected the engine’s performance, investigators could not rule out carburettor icing as a contributing factor. No other likely contributing factors were identified.

It was also found that the pilot did not ensure all of the available procedures for an engine power loss and power-off landing were followed. This resulted in reduced gliding performance and a higher-than-necessary landing speed.

The pilot had not completed a flight review in the 2 years before the accident, increasing the operational risks including responding to emergency situations.

To effectively handle emergency situations, it is vital for pilots to use their established knowledge and skills, and ensure they always do a pre-take-off emergency briefing. As well, pilots should undertake regular flight reviews. By not complying with the periodic flight review requirements, the pilot missed an opportunity to maintain those critical skills.

Read the final report: Engine power loss involving Piper Cherokee Six, VH-TSZ, Jandakot Airport, Western Australia, on 23 November 2012