Partial power loss after takeoff in single-engine aircraft — a problem that the ATSB has been emphasising to the aviation community.

A fatal accident near Hallston, Victoria has illustrated the dangers of partial power loss after take-off in single-engine aircraft — a problem that the ATSB has been emphasising to the aviation community.

The accident occurred on 1 May 2012, when the pilot of a Piper PA25 was conducting agricultural operations from a local airstrip near Hallston. Shortly after take-off, the aircraft crashed near the base of a gully and was destroyed by fire. The pilot, the only person on board, died in the accident.

...partial power loss is actually a more complex situation than a complete failure, and can be much harder to manage.

The damage sustained during the impact and ensuing fire prevented the ATSB investigation from identifying specific reasons for the aircraft’s loss of power. ATSB General Manager Strategic Capability, Mr Julian Walsh, says that partial power loss is actually a more complex situation than a complete failure, and can be much harder to manage.

"The pilot is in a situation where the engine is still providing some power, but it may be unreliable, and the available power level might be difficult to assess," Mr Walsh says.

"As a result, pilots are uncertain about their aircraft's capabilities, and what their options are— a situation that can turn into disaster very easily."

A number of resources are available to help pilots prepare themselves for a partial power loss. One of the booklets in the ATSB’s Avoidable Accidents series, Managing partial power loss after take-off in a single-engine aircraft, provides information and strategies for dealing with such a situation if it arises.

Read the final report: Collision with terrain involving Piper PA-25-235/A9, VH-GWS, near Hallston, Victoria, on 1 May 2012

The swift actions of a jet’s flight crew following a shattered windshield in flight has shown how good flight planning can make all the difference.

The swift actions of a jet’s flight crew following a shattered windshield in flight has shown how good flight planning can make all the difference.

On 15 January 2013, a Cessna Citation 750 was carrying two flight crew and five passengers from Faleolo, Samoa to Sydney, Australia.  The aircraft levelled off at 45,000 feet, when its system reported a problem with the windshield heating system.

The windshields were laminated glass with outer, middle and inner panes of glass. The pilot found that the windshield was warm to the touch, but the only advice the checklist gave was to leave icing conditions as soon as practical.

The cabin was prepared for a possible ditching, with the passengers directed by the flight crew to don their life vests and review the
safety briefing card.

Two minutes later, the outer ply of the windshield shattered with a loud bang. Cracks spread across the entire surface of the left pane.

The flight crew switched off both the left and right windshield heat switches, and completed the emergency depressurisation checklist. They donned their oxygen masks and deployed the passenger oxygen masks.

The pilots commenced an immediate descent along with a turn towards Nadi International Airport, Fiji, which was one of the planned alternate airports. The pilot declared a mayday which was acknowledged by Nadi radio. Once the descent was established, a flight crew member ensured the passengers were on oxygen and briefed them on the situation. The cabin was prepared for a possible ditching, with the passengers directed by the flight crew to don their life vests and review the safety briefing card.

During the descent, the windshield cracking did not progress further. The cabin did not depressurise, and once they were at 14,000 feet and with the cabin altitude stabilised, the passengers were directed to remove their oxygen masks. The flight continued to Nadi without further incident. There were no injuries to passengers or crew.

The ATSB investigation found that the windshield had likely been affected by moisture seeping into the heating equipment, degrading the electrical connections. The manufacturer has taken measures to the address the issue.

While the failure of the windshield did not result in a depressurisation, the precautions taken by the flight crew to descend to a lower altitude and diversion to the alternate airport highlighted the importance of good flight planning.

Read the final report: Windshield cracking event involving a Cessna 750, VH-RCA, 460 km south-east of Nadi, Fiji, on 15 January 2013

Pilots are being urged to remain focused at all stages of flight following an in-flight distraction that resulted in a fatal accident.

Pilots are being urged to remain focused at all stages of flight following an in-flight distraction that resulted in a fatal accident.

The accident occurred on 4 February 2012 shortly after a Robinson R44 helicopter lifted off from Jaspers Brush Aerodrome, near Nowra in NSW.  

During the lift off, the pilot’s door, which was not securely latched, swung open. The ATSB found that when reaching out to shut the door, the pilot likely let go of the right-hand (cyclic) control. This resulted in the helicopter abruptly pitching nose-up then steeply nose-down. It then rolled to the right and the right landing gear skid and main rotor blades struck the ground. Before the helicopter came to a stop, a fuel-fed fire started around the fuel tanks and lower mast area. Tragically, both occupants of the helicopter died in the accident.

In response to this and a number of other fatal R44 helicopter accidents, the helicopter manufacturer designed rubber bladder-type fuel tanks to replace the original all-aluminium tanks in the R44 and produced a Service Bulletin mandating their fitment.

This was not the first Robinson R44 helicopter accident to result in fatalities from post-impact fire. R44 helicopters which have all-aluminium fuel tanks have proven susceptible to post-accident fuel leaks as a result of an otherwise relatively low-energy impact, increasing the risk of a post-impact fire. In response to this and a number of other fatal R44 helicopter accidents, the helicopter manufacturer designed rubber bladder-type fuel tanks to replace the original all-aluminium tanks in the R44 and produced a Service Bulletin mandating their fitment. The Civil Aviation Safety Authority (CASA) and the ATSB have separately highlighted the safety benefits of retrofitting R44 helicopters with the bladder-type tanks.

The ATSB also issued a Safety Advisory Notice and, following another accident at Bulli Tops, near Wollongong, NSW in which a post-impact fire proved fatal, a Safety Recommendation regarding the dangers of the all-aluminium fuel tanks in the R44. Information on the safety benefits of the installation of bladder-type fuel tanks in the R44 was also circulated through the ATSB’s SafetyWatch web initiative.

Finally, on 29 April 2013 CASA issued an airworthiness directive requiring R44 helicopters fitted with all-aluminium fuel tanks to be retrofitted with bladder-type tanks and clarifying that aircraft being maintained in accordance with the Manufacturer’s Maintenance Schedule are already required to comply with all Robinson Service Bulletins in accordance with Civil Aviation Regulation 42A. More details on airworthiness directive AB/R44/23 can be found at the CASA website.

Read the final report, Loss of control involving Robinson R44 helicopter, VH-COK, Jaspers Brush Aerodrome, New South Wales, on 4 February 2012, on the ATSB website.

R44 accident site at Jaspers Brush, NSW

 

Robinson R22 helicopter pilots are being reminded to know the limits of their aircraft following the release of the ATSB investigation report into the reliability of the R22 belt drive system.

Robinson R22 helicopter pilots are being reminded to know the limits of their aircraft following the release of the ATSB investigation report into the reliability of the R22 belt drive system. 

The ATSB conducted the investigation in response to several R22 accidents and serious incidents caused by the failure of one or both rotor drive v-belts. Between 2004 and 2012, there were eight occurrences reported to the ATSB. The v-belts are crucial components which transmit engine power to the helicopter's main and tail rotor blades.

Pilots, operators and maintainers should pay particular attention to the installation and condition of R22 drive belts and other components of the drive system.

The report identifies a number of key factors that affect the reliability of the R22 drive belt system. These include:

• flying the aircraft with too much weight on board
• pushing the aircraft’s engine beyond its limits
• failing to maintain the drive system or ensuring the drive sheaves are aligned
• failing to conduct adequate or frequent inspections of the rotor drive system. 

During the investigation, the ATSB issued a safety advisory notice, cautioning Robinson R22 pilots of a drive belt risk and urging them to check their R22 helicopter drive system regularly for misalignment, abnormal wear or other indications of drive belt damage. 

The Robinson R22 helicopter is the most popular light utility helicopter used in Australia and has a reputation for being an extremely reliable machine. As of June 2012, there were over 500 Robinson R22 helicopters on the Australian Civil Aircraft Register. 

Owners and operators should fully appreciate the nature and effects of the operational stresses placed on the helicopter, particularly if the machine is used in a dynamic and demanding way.

Read the full investigation report, AI-2009-038 – Reliability of the Robinson R22 helicopter belt drive system.

ATSB is reminding rail operators of the need for effective inspection regimes and to ensure that rail components meet service requirements.

Following an investigation into the partial separation of an express passenger train, the ATSB is reminding rail operators of the need for effective inspection regimes and to ensure that rail components meet service requirements.

The investigation was initiated in August 2011, after a scheduled Melbourne to Sydney express passenger train (XPT) partially separated as it passed over a dip in the track near Broadmeadows, Victoria. The train suffered a total loss of power and was unable to continue its journey, coasting for a short distance. Initial inspection of the train suggested that the electrical disconnection was a result of the leading power car decoupling from the carriages; but it was clear that the power car and carriages stayed close together because the brake lines remained connected.

The ATSB found that the problem lay in an element of the draft gear (the connecting assembly between cars). The element in question was the tail pin, a steel component 590 mm in length. The tail pin failed as a result of an overstress fracture that was initiated by fatigue cracking – cracking that, worryingly, recent routine ultrasonic testing had not detected. Post-incident material testing established that the mechanical properties of the tail pin were below the required standard.

As a result of the investigation, a new batch of tail pins has been manufactured to an upgraded standard which includes improved quality control and acceptance testing...

Following this incident, the ultrasonic testing procedure was revised to improve the detection of smaller cracks in the tail pin. However, the separation of another XPT near Seymour, Victoria, on 1 August 2012 in similar circumstances showed that the ultrasonic testing regime was still not detecting all fatigue cracks in critical areas of the tail pin.

On 3 August 2012, the ATSB issued a safety issue notice to RailCorp, the operator of the XPT fleet, warning of the preliminary findings. Although this sort of coupler failure was extremely unlikely to lead to a derailment, the consequences of such an event involving a passenger train, should it occur at speed, were potentially very significant. In response, RailCorp set about developing a new testing process and fitting newly designed tail pins.

As a result of the investigation, a new batch of tail pins has been manufactured to an upgraded standard which includes improved quality control and acceptance testing and RailCorp is currently in the process of fitting these new tail pins. RailCorp has also further revised the tail pin inspection regime with the aim of improving its effectiveness.

This investigation did not examine how the idiosyncrasies and condition of the track may have contributed to the partial separation of the train. Those issues will be considered as part of the ATSB’s broader safety issue investigation into the interstate rail line between Melbourne and Sydney.

Read the final report: Partial train separation of XPT ST24, near Broadmeadows, Victoria, on 11 August 2011

Shipping accidents are more frequent than is widely believed but most of these accidents are preventable according to a new ATSB maritime safety report released today.

Shipping accidents are more frequent than is widely believed but most of these accidents are preventable according to a new ATSB maritime safety report released today. 

The report analyses the shipping statistics of accidents and safety incidents involving Australian-registered trading vessels (cargo and passengers) around the world or those involving trading vessels flying foreign flags within Australia’s maritime jurisdictions.

The safety of crew and shipboard workers is a significant concern for the ATSB and is highlighted as a priority in the ATSB’s SafetyWatch initiative.

Between 2005 and 2012, 245 people were killed, missing or seriously injured from reported marine occurrences. In 2012 there were 6 deaths and 33 serious injuries involving crew and shipboard workers. 

Tragically, the ATSB has found that many of these accidents were avoidable. The safety of crew and shipboard workers is a significant concern for the ATSB and is highlighted as a priority in the ATSB’s SafetyWatch initiative.

In 2012, there were 154 marine safety occurrences reported to the ATSB. This was over 50 per cent higher than the 2005–12 average of 100 occurrences each year. The increase in occurrences in 2012 was due to substantial increases in the number of reported ‘incidents’ (137) and ‘serious incidents’ (12). 

Bulk carriers and cargo vessels (including container, roll-on – roll-off cargo, heavy lift and livestock ships) have been the most common vessels involved in occurrences since 2005 and their involvement increased substantially in 2012. There were also increases in the involvement of tankers, offshore support vessels and tugs. 

The number of foreign vessels involved in occurrences grew considerably in 2012. This was predominantly due to an increased involvement in incidents (up 55 per cent on 2011), but there were also more foreign registered vessels involved in serious incidents. The number of Australian registered vessels involved in occurrences also increased in 2012 and the highest number of occurrences recorded was by Australian, Panamanian and Singaporean registered vessels. 

The ATSB is encouraging operators to learn from the experiences of others in the industry to help identify the safety risks in their operation that could lead to a similar accident or serious incident.

Read the full research report, Australian Shipping Occurrence Statistics 2005 to 2012 (MR-2013-002).

The ATSB has just released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 17 covers short, office-based investigations.

The ATSB has just released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 17 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 one of the occurrences, there were serious 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:

• Wake turbulence event involving a Boeing 737, VH‑YIO 
• Windshield cracking event involving a Cessna Aircraft 750, VH-RCA 
• Airspace related event involving Beech 1900C, VH-KFN and Aerospatiale AS350 B2, VH-VRW
• Runway loss of separation between Bombardier DHC-8, VH-ZZJ and Aerospatiale, VH-LOJ
• Pilot incapacitation event involving a Hawker B200, VH-FDT
• Loss of separation involving a Cessna 310, VH XXT and a Cessna 210, VH RQD
• Engine failure involving Cirrus SR22, VH-WYH 
• Loss of performance involving DH-82A (Tiger Moth), VH-DDA
• Aircraft proximity event between an Alpha Aviation R2160, VH-NZT and a Diamond DA 40, VH-UNH
• Loss of control involving a Robinson R44, VH-RYO

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 17

A runway accident involving a Cessna T210 reinforces the need for pilots to take extreme care when using unsealed runways.

A runway accident involving a Cessna T210 reinforces the need for pilots to take extreme care when using unsealed runways.

The accident happened on 30 December 2012 when the Cessna, with a pilot and five passengers on board, was taking off from Cape Leveque airfield in WA. Cape Leveque is an unlicensed airfield managed by a tourist operator. It comprises a 972 m long and 40 m wide strip of compacted soil. There had been rain on the strip during the previous days and an early shower on the day of the accident. The airfield is monitored for serviceability and was deemed suitable on the day of the flight; however, after the accident an inspection of the airstrip revealed that there had been a substantial washout on the edge of the strip. The managers closed the airstrip for grading and repair.

Early in the take-off, the Cessna veered to the left. The pilot tried to straighten the aircraft with rudder and continue with the take-off, but ended up about a metre left of the runway centre line. About halfway down the runway the aircraft veered sharply to the left again. The pilot again tried to correct the veer, but the aircraft did not respond. He slowed the aircraft before the left wing clipped trees along the edge of the airstrip, making the aircraft swing almost 90 degrees before the right wing struck the ground. The nose-wheel collapsed in the soft sand on the edge of the airstrip resulting in the propeller striking the ground. One of the passengers sustained minor injuries and the aircraft was substantially damaged.

After the accident, the pilot of the second aircraft inspected the airstrip and reported substantial washout on the edge of the strip inside the cone markers.

As a result of this accident, the aircraft operator has reinforced the need for their pilots to:

• keep the nosewheel on the centreline of the runway at all times
• use the right rudder during take-off
• where possible avoid loose dirt and rough areas on the side of the runway
• close the throttle immediately, if the take-off needs to be rejected
• always use the checklist
• not to rush.

Read the final report: Runway excursion involving Cessna T210, VH DQI, at Cape Leveque, Western Australia, on 30 December 2012

A go-around is always a viable option when pilots experience any problems during landing.

A go-around is always a viable option when pilots experience any problems during landing. The ATSB emphasised this point after a pilot, partially blinded by glare, opted to continue his landing, and as a result his aircraft departed the runway and travelled through two fences before coming to a stop.

The accident occurred on 23 August 2012, at Urapunga in the Northern Territory. The aircraft was a Cessna 210N, carrying the pilot and two passengers on a charter flight. While the aircraft was descending, the sun created a glare on the windscreen that greatly restricted visibility.

The pilot was wearing non-polarised sunglasses, which helped only slightly. The aircraft’s sun visors were not effective because the sun was low on the horizon. Nevertheless, the pilot thought he could identify the runway through the glare and saw what he thought was the runway centreline, so he continued his approach.

The pilot reported intermittent 
sun glare during descent...

As the aircraft floated down above the runway, the pilot was unsure of the amount of runway that had been used. The aircraft touched down and the pilot applied heavy breaking in short bursts. The aircraft slowed a little on the runway’s gravel surface before leaving the end of the runway, and travelling through two fences.

The aircraft came to rest on the right side of the fuselage, right wing and right horizontal stabiliser. The pilot received minor injuries from barbed wire while he was evacuating from the aircraft.

There are several studies by the US Federal Aviation Administration and the ATSB on overruns and the value of being prepared to go around.

Links to those studies and related briefing notes can be found in the investigation report, AO-2012-107.

Flat light can completely obscure features of the terrain, creating an inability to distinguish distances and closure rates.

On 9 December 2012 the pilot of a Robinson R22 helicopter took off from a fishing camp at the mouth of the Normandy River in Queensland on a private flight.

The pilot was flying north along the coastline at about 600 ft above the ground when he saw an object in the water about 100 m from the coast. The pilot turned the helicopter towards the object and descended to take a closer look.

As the pilot approached the object the helicopter’s tail rotor hit the water which caused the helicopter to rotate to the right before the pilot lost control. The pilot closed the throttle, and the helicopter settled into the water, before rolling over to the right. Unharmed, the pilot escaped via the passenger door and swam to shore before walking back to the fishing camp he left earlier.

Flat light can completely obscure features of the terrain, creating an inability to distinguish distances and closure rates.

The pilot reported that the wind was about 20 knots with a high smoke haze and flat light conditions. Flat light is an optical illusion also known as ‘sector or partial white out’ that causes pilots to lose their depth-of-field and contrast in vision. Flat light conditions are usually accompanied by overcast skies inhibiting good visual clues. These conditions can occur anywhere in the world, primarily in snow covered areas but can also occur in dust, sand, mud flats or over water. Flat light can completely obscure features of the terrain, creating an inability to distinguish distances and closure rates. It can give pilots the illusion of ascending or descending when actually flying level.

The dangers of flying helicopters over water have long been recognised. In July 1985 Robinson Helicopter Company issued

about the hazards of flight over water, making special reference to the potential for pilots’ loss of depth perception over water. The safety notice recommended maintaining a height of 500 ft AGL and avoiding manoeuvres over water below 200 ft AGL.

Read the final report: Loss of control involving a Robinson R22, VH-HTD, Princess Charlotte Bay, Queensland, on 9 December 2012