Pilot pressure and the layout of a non-towered aerodrome contributed to an airspace incident between a Beech 1900C and an Aerospatiale AS350 B2 helicopter, according to an ATSB investigation.

The incident occurred on 6 September 2012 at Newman Aerodrome in Western Australia. The Beech had made all required radio broadcasts and was on its take-off roll when the pilot saw the Aerospatiale helicopter unexpectedly enter the runway strip and take off parallel to the runway. The pilot of the Beech believed the paths of the two aircraft could cross if they both became airborne and, although his airplane was by this time moving at about 222 km/hr, he aborted the take-off. As the aircraft slowed, he saw the helicopter turn right and cross the runway about 200 m in front of the Beech and about 200 ft above ground level.

The pilot of the helicopter only became aware of the Beech when he heard the Beech’s co-pilot broadcasted that he was aborting the take-off. The Aerospatiale pilot made all required radio broadcasts but heard only one garbled transmission which may have been the Beech’s ‘rolling’ call.

New hangars had recently been built at Newman, which obscured the view from the GA apron to the threshold of the runway.

The pilot of the helicopter later explained that he had received word that a person at a survey site had been injured and required immediate evacuation. Feeling pressure to get to the injured person, he had turned right across the runway when the normal procedures required him to turn left.

At and around non-towered aerodromes, pilots are responsible for making themselves aware of nearby aircraft and maintaining separation. However, new hangars had recently been built at Newman, which obscured the view from the GA apron to the threshold of the runway. The hangars were also thought to be responsible for blocking radio transmissions between aircraft on the GA apron and those on the threshold of runway.

In response to this incident, the airfield operator is seeking to have a warning included in the aviation information publication for Newman. This warning describes the possible shielding effects from the aircraft hangars and requires adherence to specific procedures for helicopter arrivals and departures.

A study by the National Aeronautics and Space Administration (NASA) has found that perceived or actual pressure can contribute significantly to degradation in human performance and behaviour. The study recommended that pilots be particularly cautious if distraction or time pressure are encountered during the pre-flight or taxi phases of a flight.

The ATSB investigation report, AO-2012-118, contains links to useful resources on pilot pressure.

The SafetyWatch web resource also contains important information on safety in the vicinity of non-towered aerodromes.

The ATSB and CASA have agreed a policy statement for further consultation on accident and incident notifications received from the aviation industry.  The policy relates to the disclosure and use of information for safety purposes and follows consultation on this issue in 2012. 

You can read the statement by clicking on the link below.

• Policy statement: Mandatory notification information sharing

The engine failure of a Cirrus SR22 aircraft shows why it’s vital to always follow the aircraft manufacturer’s operating guidance.

The ATSB’s investigation into the engine failure of a Cirrus SR22 aircraft shows why it’s vital to always follow the aircraft manufacturer’s operating guidance. 

During a flight from Emerald, Queensland to Dubbo, NSW on 21 November 2012, the engine indications on the Cirrus SR22 were showing a gradual loss of oil pressure. Despite the pilot’s operating handbook advising the pilot to promptly land the aircraft to find the cause of the oil pressure loss, he decided to monitor the situation after contacting the maintenance organisation for advice. 

The oil pressure continued to drop and eventually the engine failed when the aircraft was 11 minutes from Dubbo, near Gilgandra. The pilot was not able to land at the Gilgandra airport and elected to deploy the ballistic parachute system fitted to the aircraft. The aircraft landed upright in a paddock and fortunately, the pilot and the passenger escaped with minor injuries. 

The pilot commented that the oil pressure indication dropped very gradually, giving a false sense of security. Three or four weeks previously, the aircraft’s engine temperature probe had failed. As the engine cylinder head temperature and oil temperature indications remained in the normal range, the pilot thought that the low oil pressure may have indicated another faulty probe. 

The aircraft had flown only around 4 hours following a 100 hour maintenance check. When the pilot conducted the pre-flight check for the accident flight, he noted that the oil level was below 5 quarts and 1 L of oil was added to the engine. The pilot’s operating handbook notes that the engine should not be operated with less than 6 quarts of oil and 7 quarts is recommended for extended flights.  

Read the final report: Engine failure involving a Cirrus SR22, VH-WYH, 7 km south of Gilgandra (ALA), New South Wales, on 21 November 2012

The ATSB has just released a new aviation bulletin containing 9 investigation reports. The Aviation Short Investigation Bulletin Issue 19 covers short, office-based investigations.

The bulletin covers incidents, serious incidents and accidents involving jet, turboprop and piston aircraft and helicopters. None of the accidents were fatal; however, some of the aircraft suffered substantial damage and in some occurrences, people suffered injuries.

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:

• Take-off without runway lighting involving Airbus A320, VH-JQG
• Runway incursion between a Fairchild SA227, VH-WBA and a vehicle
• Loss of ground control involving a PZL-Mielec M18A Dromader, VH-TGY
• Collision on ground involving Cessna 150F, VH-ICE
• Landing on a closed runway involving a Cessna 310, VH-TWN
• Runway incursion between a Cessna 206, VH-TOC, and an airport safety vehicle
• Collision on runway between Grob G103 Twin Astir glider, VH UIZ and Cessna 150F, VH ROZ
• Wildlife strikes involving a Mooney M20J, VH-CYK
• Wirestrike involving Robinson R44, VH-HGF

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 19

The ATSB is urging port managers and operators to consider all the risks associated with operations within their ports following the foundering of a ship at Christmas Island in 2012.

The ATSB is urging port managers and operators to consider all the risks associated with operations within their ports following the foundering of a ship at Christmas Island in 2012. 

On the morning of 8 January 2012, one of the permanent mooring lines holding the general cargo ship Tycoon in position at Flying Fish Cove, Christmas Island, came free from its anchor. As a result, the ship moved forward and closer to the nearby terminal rock face, eventually hitting the rock face as the weather and sea conditions deteriorated. 

Despite attempts to move it away, Tycoon continued to pound against the rock face. Eventually, the ship’s engine room began to flood through a tear in the hull. Shortly afterwards, the crew safely abandoned the ship.

The next day, Tycoon suffered a catastrophic failure of its hull and the contents of the ship’s number two cargo hold, about 260 tonnes of bagged phosphate, were exposed to the sea. The ship continued to be pounded by the sea and swell and, over the following months, it broke up. The wreck was eventually removed by salvors on 26 July 2012.

The ATSB investigation found that the shackle connecting the port’s mooring line to its anchor chain had failed. As well, Tycoon’s master did not advise shore authorities of his concern about the deteriorating conditions or that the mooring line had come free. He also did not make proper use of the ship’s main engine or mooring lines in an attempt to keep the ship in position after the mooring line came free. 

...the ship’s engine room began to flood through a tear in the hull.

In addition, it was found that there had been no risk assessment undertaken by successive port managers with respect to the use of the inner moorings and that there was little guidance provided to the masters of ships intending to moor in Flying Fish Cove. The managers of the port had not implemented an effective inspection and maintenance program and therefore were not aware of the deteriorated condition of the mooring line shackle.

As a result of the accident, the port operator has commenced replacing and upgrading the mooring equipment. They are also developing a Port Handbook which will be provided to the master of each ship and are facilitating safety training workshops that will be a forum through which the risks posed to the port and its operations can be assessed.

The ATSB investigation report advises port authorities to have procedures and contingency plans in place to deal with foreseeable emergencies. In addition, it is vital that there be effective maintenance and inspection regimes to ensure the good order of equipment and facilities.

Read the final report: Foundering of the general cargo ship Tycoon, Christmas Island, on 8 January 2012

A new ATSB report examines the effectiveness of emergency locator transmitters (ELTs) and reveals how pilots can increase their chances of being rescued after an aviation accident.

A new ATSB report examines the effectiveness of emergency locator transmitters (ELTs) and reveals how pilots can increase their chances of being rescued after an aviation accident. 

ELTs are radio beacons carried in most aircraft to help search and rescue authorities quickly locate an aircraft following an accident. However, data from the ATSB occurrence database shows that ELTs are only functioning as intended in about 40 to 60 per cent of accidents. 

The report reveals that pilots and operators of general aviation and low-capacity aircraft cannot rely on a fixed fuselage-mounted ELT to activate when required. Also, carrying a personal locator beacon will most likely only be beneficial to safety if it is carried on the person, rather than being fixed or stowed elsewhere in the aircraft. Additionally, the effectiveness of ELTs in increasing occupant safety and assisting search and rescue authorities' efforts may be enhanced by:

• using a GPS-enabled ELT
• using an ELT with a newer 3-axis g-switch
• ensuring the ELT is installed correctly
• ensuring the beacon is registered with the Australian Maritime Safety Authority (AMSA)
• pre-emptively activating the beacon if a forced landing or ditching is imminent.

Despite these concerns, the report shows data from the AMSA Search and Rescue incident database, indicating that ELT activations have been directly responsible for saving an average of four lives per year.  

Read the ATSB research report: AR-2012-128 A review of the effectiveness of emergency locator transmitters in aviation accidents

The ATSB has just released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 18 covers short, office-based investigations. 

The bulletin covers incidents, serious incidents and accidents involving jet, turboprop and piston aircraft and helicopters. None of the accidents were fatal; however, some of the aircraft sustained substantial damage and, in some occurrences, people suffered injuries.

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:

• Significant wind change during take-off involving Boeing 737, VH-VZL 
• Aircraft proximity event between a Piper PA-28, VH-PZK and a Cessna 441, VH-VEJ 
• Aircraft proximity event between a Beech B200C, VH-AMQ and a Ventus glider, PH-1234
• Aircraft proximity event between a Beech B200C, VH-VAE and an unidentified glider
• Wirestrike involving an Ayres Thrush S2R-T34, VH-HAH
• Power loss (both engines) involving Piper PA-39, VH-RMA
• Aircraft proximity event between a Piper PA-44, VH-MHZ and a Hawker G36, VH-JKL
• Engine failure involving a Cessna 182R, VH-OWZ
• Wheels up landing involving a Cessna 337F, VH-JUP
• Loss of control involving Robinson R22, VH-HGI

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 18

The ATSB is warning of the dangers of improvising or modifying established procedures after a winching accident resulted in the death of a paramedic.

The ATSB is warning of the dangers of improvising or modifying established procedures after a winching accident resulted in the death of a paramedic.

On Christmas Eve 2011, an emergency personal locator beacon was activated in the Budderoo National Park, about 16 km south-west of Wollongong, NSW. A rescue helicopter at Bankstown Airport was assigned to track to the beacon and departed, carrying a pilot, an air crewman, two paramedics and a doctor.

The crew located the beacon at a waterfall known as Bridal Veil Falls. A canyoner’s abseiling rope had failed, and he had fallen onto a rock ledge near the bottom of the falls, suffering serious injuries. 

The crew conducted an aerial reconnaissance of the area and assessed that, because of the terrain and vegetation, it would not be possible to winch personnel directly to the injured canyoner’s position and that vertical winch retrieval would similarly not be possible. Instead, the pilot landed at a nearby clear area and the crew devised a plan to access and retrieve the patient. 

As the helicopter moved toward the position to commence the retrieval, the paramedic and the patient were accidentally pulled from the ledge and fell several metres, hitting rocks.

One of the paramedics abseiled down to the patient, taking the end of a second rope (the tag line) with him. The other paramedic remained at the top of the waterfall, holding the other end of the line. The helicopter hovered over the top of the waterfall and lowered the winch hook, and the tag line was used to facilitate delivery of the hook to the ledge. Because the helicopter could not hover directly over the patient’s location, it hovered off to the side, and the idea was for the paramedic and the patient to move out under it, and use a stabilising rope attached to the terrain to ensure they did not swing.  

Due to fading light, and issues with the use of radios it was difficult for the parties in the helicopter and on the ground to communicate effectively. As the helicopter moved toward the position to commence the retrieval, the paramedic and the patient were accidentally pulled from the ledge and fell several metres, hitting rocks. The paramedic died from the impact. The patient was subsequently transported to hospital for treatment.

The ATSB investigation into the accident identified several safety issues relating to training and to the use of the helicopter’s lighting and radios. 

As a result, the Ambulance Service of New South Wales and the helicopter operator have taken a number of measures to improve the safety of their operations. These safety actions have included revising their procedures, expanding their training programs, and impressing upon their staff the importance of adhering to appropriate procedures. 

Rescue crews are frequently confronted with difficult situations and may be presented with rescue tasks they have not previously experienced. However, if they implement procedures that are not documented, or for which they have received no training, then it can be extremely difficult to identify hazards and manage the related risks.

Read the final report: Helicopter winching accident involving an Agusta Westland AW139, VH-SYZ, 16km west-south-west of Wollongong Airport, New South Wales, on 24 December 2011

Passengers are being reminded to fasten their seatbelts at all times while seated.

Aircraft passengers are being reminded to fasten their seatbelts at all times while seated after a Virgin Boeing 737 encountered wake turbulence.

The incident occurred on 13 September 2012 when the aircraft, carrying 132 passengers, was en route from Bali to Brisbane. While in cruise, the 737’s crew spotted an aircraft above, approaching from the opposite direction. The aircraft passed about 0.9 Nautical Miles to the left and 1,400 ft above.

About one minute later, the 737 experienced cobblestone-like turbulence. It then rolled slightly to the right and then suddenly to the left to an angle of about 40°. The crew managed to arrest the roll and straighten the aircraft. The incident occurred as a result of wake turbulence from an Airbus A380 aircraft.

A wake turbulence encounter can be a surprising experience for both the crew
and passengers...

Fortunately all the aircraft’s passengers were seated at the time of the incident and there were no reported injuries. The flight continued without further incident.

Pilots receive six-monthly jet upset simulator training to prepare them for situations when an aircraft experiences pitch or roll conditions greater than normal. Both the captain and the first officer of the 737 had received their training within the past two months—the captain’s training took place within the week before the incident. They both reported that the training was invaluable, with the first officer remarking that his response to the wake turbulence had been instinctive and that the incident was similar to that experienced in the simulator.

A wake turbulence encounter can be a surprising experience for both the crew and passengers and usually results in induced rolling or pitch moments. A safety bulletin published by the ATSB, Staying Safe against In-flight Turbulence, noted that almost all turbulence injuries involve people who are not properly seated and do not have their seat belt fastened. This incident is a timely reminder to have your seat belt fastened, even when the seat belt sign is turned off, so that injuries during a turbulence encounter can be minimised.

Read the final report: Wake turbulence event involving a Boeing 737, VH-YIO, 258 km south-east of Bali International Airport (Denpasar), Indonesia, on 13 September 2012. The report includes links to valuable information on wake turbulence.

An unmanned airship was on a test flight when its remote-pilot lost control. Read more...

An unmanned airship was on a test flight in Keysborough, Victoria when its remote-pilot lost control before the aircraft flew into the controlled airspace of Moorabbin Airport.

The incident occurred on 28 October 2012, when a team comprising a pilot, observer and software engineer were conducting a test flight of the airship. The aircraft, weighing less than 8 kg, consisted of a 10 m long balloon with a gondola suspended below and was remotely controlled by the pilot using a portable radio-controlled transmitter. The crew planned to fly the airship below 200 ft and within 200 m of their location to ensure it remained clear of the Moorabbin Class D control area. 

Shortly after take-off, the crew noticed that the airship’s nose was tilting up due to its rearward centre of gravity. The pilot corrected the tilt but a minute later, when the aircraft was at about 130 ft off the ground, he realised that he could not turn it to the left, although it still could turn right. 

The pilot attempted unsuccessfully to contact the Moorabbin control tower by radio to advise them of the situation.

The pilot tried to land the airship, but the rearward centre of gravity resulted in it climbing. The airship’s elevator (or height) controls were also not responding. As it climbed through 200 ft above the ground, the pilot realised he had lost total control of the airship, He reduced the engine power, but the airship continued to climb and fly in a north-westerly direction toward the Moorabbin Airport. 

The pilot attempted unsuccessfully to contact the Moorabbin control tower by radio to advise them of the situation. He and the software engineer then got in a car with the portable radio-controlled transmitter to follow the airship by road. The observer remained at Keysborough and contacted the Moorabbin control tower and emergency services via telephone. 

The air traffic controllers at Moorabbin spotted the airship around 4 km to the south-east at about 1,000 ft above the ground. This was also confirmed by the pilot of an aircraft flying in the Moorabbin circuit. 

Thirty minutes later, the airship landed on the roof of a commercial building, sustaining minor damage. 

Data provided to the ATSB by the airship operator indicated that the airship reached a height of 1,930 ft and, at its closest, was 5 km from Moorabbin Airport.

The airship operators have advised the ATSB that they will take a number of measures to prevent similar incidents. This includes developing a pre-flight checklist and change management process to consider risks when changes are made to hardware or processes. They will also be locating a suitable site for flight testing away from populated areas.

There are regulations that set out the requirements for the operation of unmanned aircraft (including airships); however, the size of the airship’s balloon meant that it did not have to be registered, and it was not subject to airworthiness and flight crew qualification requirements. 

The Civil Aviation Safety Authority is currently working to provide more comprehensive guidance on the regulatory requirements and approval processes for the commercial operation of unmanned aircraft systems in Australia. The guidance will consider the long-term integration of unmanned aircraft systems into normal aviation operations in all classes of airspace.

More details of the safety actions and the civil aviation regulations can be found in the investigation report Airspace incursion involving unmanned airship, Airship 11, 2.7 NM east of Moorabbin Airport, Victoria, on 28 October 2012