The wheels-up landing of a Beech A36 is a good example of how pilot ‘distraction, pre-occupation, channelized attention or panic’ can lead to dangerous outcomes.

The wheels-up landing of a Beech A36 is a good example of how pilot ‘distraction, pre-occupation, channelized attention or panic’ can lead to dangerous outcomes.

On 12 November 2012 a Beech A36 aircraft, VH-SQI (SQI) was conducting a fire inspection flight. On board were the pilot and one passenger. The aircraft took off from Meekatharra, WA bound for Kumarina where it conducted a 45-minute flight to observe nearby fires.

At about 0850 the pilot and passenger prepared to depart Kumarina for further inspection of fires in the area. During the take-off run, the forward cabin door, located next to the passenger, opened. The pilot elected to continue his take-off. The passenger was slightly alarmed by the opening of the door, but the pilot reassured him that it was fine and that they would return and land.

Just before landing the pilot realised that he had not done his pre-landing checks and had forgotten to lower the landing gear.

The pilot conducted a tighter and lower-than-normal circuit to expedite the landing, and decided to leave the aircraft in the take-off configuration to reduce his workload. He did, however, retract the landing gear. During the shorter circuit the pilot focused on locating a communications tower north of the runway within the circuit area. The pilot commented that he felt pressured and did not conduct his normal downwind and pre-landing checks as he believed the aircraft was already configured for landing.

Just before landing the pilot realised that he had not done his pre-landing checks and had forgotten to lower the landing gear. The plane landed with the wheels up and skidded to a halt about 200m down the runway. The pilot and passenger were uninjured, but the plane was substantially damaged.

The pilot reported that fatigue and workload may have contributed to the accident. He had flown the previous day and stayed at Meekathara overnight due to the approach of last light, and had started duty on the day of the accident at 0400 in the morning. The pilot also reported the workload of handling the abnormal situation, his concern about the passenger, a potential obstruction in the circuit, and his decision to rush the circuit all contributed to missing his downwind and final pre-landing checks and failure to lower and confirm the position of the landing gear.

Read the final report: Wheels up landing involving Beech A36, VH-SQI, Kumarina Roadhouse airstrip, Western Australia, on 12 November 2012

The ditching of a Robinson R44 helicopter into the ocean 80 km north of Horn Island shows how good preparation greatly improves the chances of survival and rescue.

The ditching of a Robinson R44 helicopter into the ocean 80 km north of Horn Island shows how good preparation greatly improves the chances of survival and rescue.  The ditching took place on 9 June 2012 during a return flight from Dauan Island to Thursday Island.

Earlier that day, on the way to Dauan Island, the helicopter’s alternator light illuminated on two separate occasions. Both times, the pilot turned the alternator off and then back on and the light went out. Later, when the pilot started the engine for the return flight from Dauan Island, the engine rotated several times and made a clicking sound ‘like a battery without enough power’.

After consulting with the operator, the pilot used truck batteries to start the helicopter. He ran the engine at idle power for about 10 minutes before departing for Horn Island.

Fortunately, the pilot had taken precautions before commencing the flight—precautions that enabled him to land the helicopter safely, summon help, and be located by the search and rescue team.

About 10 minutes after departing, the alternator light illuminated again. The pilot turned the alternator off and back on again and the light went out. This happened three more times before the pilot isolated all non-essential electrical systems. By then, he had passed the point of no return to Dauan Island and decided to fly to Moa Island instead. Continued trouble with the engine, however, indicated a possible engine overspeed, so he deployed the helicopter’s emergency ‘pop-out’ floats and landed in one metre of swell. The pop-out floats allow the helicopter to float on the water surface.

Fortunately, the pilot had taken precautions before commencing the flight—precautions that enabled him to land the helicopter safely, summon help, and be located by the search and rescue team.

A few years previously, he had undertaken ditching training, and was prepared for a water landing. After landing safely, he shut down the helicopter and, since the conditions were reasonably stable, remained in the cockpit, wearing a life jacket equipped with flares. He activated his personal locator beacon (PLB) and attempted to contact the Horn Island police on his mobile phone, but the signal dropped out. He then used his mobile phone to contact the helicopter operator, who initiated a search and rescue operation by contacting the Rescue Coordination Centre Australia. Shortly after, the signal from the PLB was detected by the Cospas-Sarsat satellite system. In addition, the pre-arranged SARTIME (a time nominated by the pilot for search and rescue proceedings to begin) was reached, and the automated software initiated.

The crew of the search and rescue helicopter were not able to determine an accurate location from the PLB signal since it remained within the helicopter fuselage, but they navigated to the pilot using the flares that he discharged. The pilot was rescued uninjured; however, the helicopter sustained substantial damage due to the salt water. It was recovered the next day.

A detailed examination of the helicopter following the accident found evidence of an engine overspeed. As a result of this occurrence, the aircraft operator has, among other actions, amended company policy in relation to a flat battery and faulty alternator, requiring immediate replacement. In addition, the lanyard on the PLB has been extended from 0.5 m to 3 m, allowing the PLB to be thrown clear of the helicopter. Pilots have also been briefed in the use of noise-cancelling headsets, after the pilot reported that his headset may have dampened the abnormal engine sounds.

The full report of AO-2012-096 is contained within the Aviation Short Investigation Bulletin – Issue 15.

A fatal shipping accident in Brisbane had demonstrated the dangers of complacency, even when— perhaps especially when—undertaking routine tasks.

A fatal shipping accident in Brisbane demonstrates the dangers of complacency, even when undertaking routine tasks.

On 15 December 2011, the crew of the British Beech were taking on stores from a barge when, during the return of a stores container from the ship to the barge, the container came free of its slings. The container fell to the barge below, striking the master of the barge. The barge crew and shore paramedics attended to the master, but he died from his injuries while being transported to hospital.

The barge master placed himself in a position of danger under the suspended load, and the barge crew had not followed their company procedures for storing operations.

Lifting operations, even when they are routine, involve inherent risks. The ATSB investigation found that the ship’s crew did not view the storing operation as dangerous and had, over time, removed identified safety barriers which would probably have prevented the accident. The container had not been appropriately rigged on board the ship and the ship’s crew had not warned the barge crew of its return.

In addition, on the barge, the barge master placed himself in a position of danger under the suspended load, and the barge crew had not followed their company procedures for storing operations.

The companies of both vessels were found not to have adequately implemented compliance auditing processes. In the case of the barge company, there had been previous incidents which, though less serious, had not been acted on or learnt from. Effective compliance auditing could have caught and pre-empted some of the dangerous practices which resulted in the accident. The ATSB urges that established procedures be followed, reinforced and audited in order to ensure that vigilance is maintained and complacency avoided.

As a result of the accident and investigation, the method for handling these types of containers in Brisbane has changed so that the containers are top lifted and slings are no longer used. The ship’s manager, BP Shipping, has also implemented a thorough review of lifting and slinging processes, practices, procedures and equipment. A fleetwide review and training workshop for lifting and slinging was also completed.

This is one of several accidents that the ATSB has investigated which involved unsafe working practices in the maritime industry. Unsafe maritime work practices forms the subject of one of the ATSB’s Safety Watch articles. Safety Watch identifies safety concerns that deserve heightened attention.

Full details of the safety actions taken by both the ship’s manager and the barge’s operator can be found in the investigation report: Fatality while storing the products, tanker British Beech, in Brisbane, Queensland, on 15 December 2011

An incident at Jabiru, Northern Territory demonstrates the importance of both un-alerted and alerted see-and-avoid principles and of pilots checking the serviceability and correct operation of radio equipment before flying.

On 5 October 2012, a Beech 1900, registered VH-EMK (EMK) departed Darwin on a charter passenger flight to Jabiru. When descending into Jabiru, the crew broadcast on the Brisbane Centre frequency advising that they were 40 NM west of Jabiru, and were due to arrive at 0654. Brisbane Centre air traffic control advised that there was no traffic for the descent.

At about 0645, an Airparts FU-24 aircraft, registered VH-HVP (HVP) was being prepared for an aerial survey flight in the Jabiru area. During flight preparations the pilot turned the aircraft’s radio on and selected standby on the transponder. Shortly after, the pilot broadcast on the common traffic advisory frequency (CTAF) that he was taxiing for runway 27. At that time the pilot heard a broadcast from the crew of EMK advising that they would be established on a 5 NM final at 0654. The pilot of HVP determined that he would have 4 minutes to depart before EMK was reported to be established on its final approach.

Pilots should make use of all available resources such as an Aerodrome Frequency Response Unit (AFRU) to confirm radio serviceability.

The pilot of HVP broadcast a call advising that he was entering and backtracking runway 27 and selected ‘ALT’ on the transponder. The pilot reported that he received no reply to his broadcast and believed there was no conflict with EMK.

When about 1 NM inbound, the crew of EMK saw HVP taking off on runway 27 directly opposite their approach path. The captain immediately called for a go-around, which the first officer (FO) initiated. The FO took avoiding action by manoeuvring to the right. At the same time the pilot of HVP saw EMK on final for runway 09 and decided to continue the take-off as he did not wish to remain on the runway if the crew of EMK had not seen HVP. After take-off, the pilot of HVP turned the aircraft to the right to maintain separation from EMK.

Following the incident the crew of EMK tried to contact HVP three times, but received no reply and HVP was not observed on the TCAS (traffic collision avoidance system) display. The pilot of HVK heard a broadcast from EMK and tried to respond, but realised that his radio was only receiving and not transmitting. The two crews reported different assessments of the minimum separation of the two aircraft, but it appears that separation reduced to about 300 ft vertically and 200 to 250 m horizontally.

HVP’s communications equipment comprised a VHF radio, a HF radio and a satellite phone. A single radio selector switch was used to activate each system. The pilot of HVP reported using the satellite phone the previous day. When changing the selection back to VHF he had inadvertently placed the selector between the VHF and HF settings. He did not confirm the radio selection during pre-flight checks. The crew of EMK reported that HVP was not observed on the TCAS.

The practice of ‘see-and-avoid’ has long been the primary method for minimising the risk of collision when flying in visual meteorological conditions in uncontrolled environments and is considered a crucial element of a pilot’s situation awareness. The use of a radio, combined with a visual lookout, markedly increases effectiveness; however, pilots need to be mindful that the absence of a traffic broadcast does not necessarily mean the absence of traffic. In addition, pilots should make use of all available resources such as an Aerodrome Frequency Response Unit (AFRU) to confirm radio serviceability.

Read the final report: Aircraft proximity event between Beech 1900, VH-EMK and Airparts FU-24, VH-HVP, Jabiru Airport, Northern Territory, on 5 October 2012

Limitation of the see-and-avoid principles

On 17 November, 2012, a pilot approaching Geelong (Grovedale) airstrip in a Piper PA-28R was feeling some apprehension.

On 17 November 2012, a pilot approaching Geelong (Grovedale) airstrip in a Piper PA-28R was feeling some apprehension: he did not hear any broadcasts from aircraft operating at the airstrip and could not see any aircraft on the ground.

The pilot considered diverting to Barwon Heads, but for a number of reasons, he decided to continue to Geelong. He conducted a precautionary flight over the runway, and he and his passenger saw no signs indicating the airstrip was closed. There were cars and umbrellas on the ground, and the runway appeared the same as it had when he had visited on previous occasions. He elected to land.

The pilot had a message on his home phone and mobile from Airservices Australia
advising that Geelong was closed.

After landing safely, the pilot noticed that the office buildings were unoccupied and a fence had been placed across one of the runways. He was later told by people on the ground that the airstrip had been closed since April and was going to be redeveloped as a residential estate.

This incident demonstrated the vital importance of reviewing all available flight information, including the condition and suitability of the selected landing areas. When preparing for the flight, the pilot looked at a number of potential landing areas including Barwon Heads and Geelong. The pilot initially referenced the En Route Supplement Australia (ERSA) and noted that there was airstrip information for Barwon Heads, but not Geelong. He then referred to the Aircraft Owners and Pilots Association of Australia (AOPA) National Airfield Directory 2010/11 to obtain runway information for both airstrips. The latest edition of the AOPA Directory (2012) was released at about the same time the incident occurred. It stated that the Geelong (Grovedale) airstrip was closed.

When an aerodrome is rendered completely unserviceable for all operations, an unserviceability cross marker is displayed in the signal circle (a coloured area near the windsock that is used for displaying ground signals to pilots). During the precautionary flyover, the pilot and passenger did not see any cross markers, although they did observe a light coloured section near the end of the runway. 

After landing, the pilot contacted Airservices Australia to cancel his SARTIME (the time nominated by a pilot for the initiation of Search and Rescue action if a report from the pilot has not been received by the nominated unit.) As they acknowledged the cancellation, the Airservices employee made reference to Barwon Heads as the planned destination. When he returned to Bairnsdale, the pilot noted that he had a message on his home phone and mobile from Airservices Australia advising that Geelong was closed and his flight planned destination had been changed to Barwon Heads.

Read the final report: Landing on a closed airstrip involving a Piper PA-28R, VH-HKZ, Geelong (Grovedale), Victoria, on 17 November 2012, which provides more detail on the incident and the advice of the ATSB.

Pilots and operators of Bombardier DHC-8-100, -200 and -300 series aircraft are being urged to take steps to reduce the risk of propeller overspeed following an incident involving a DHC-8-315 aircraft.

Pilots and operators of Bombardier DHC-8-100, -200 and -300 series aircraft are being urged to take steps to reduce the risk of propeller overspeed following an incident involving a DHC-8-315 aircraft. 

The incident occurred on 6 December 2011 when the aircraft, operated by QantasLink, was on a scheduled flight from Cairns to Weipa in Queensland. The first officer was the pilot flying. The aircraft was descending, with the power levers in the flight idle position and the first officer’s hand on the power levers, when it entered a layer of cumulus cloud. There were a few small bumps from the turbulence. A few seconds later, the aircraft encountered a strong updraft followed by a downdraft, which caused the first officer to inadvertently lift one or both of the idle gate release triggers and move the power levers below the flight idle gate 

The flight idle gate is a mechanical stop that assists with preventing the power levers from going into ground beta mode. Ground beta is a control mode used to control the pitch of the propeller blades during ground operations. Because ground beta mode inhibits propeller speed governing, pilots are prohibited from using it while in the air. 

The ATSB found that while the beta warning horn sounded as designed, the pilots were not acutely aware of the purpose of the warning horn due to a lack of previous exposure to the sound.

In the cockpit, the beta warning sounded, and the propeller noise increased. The captain initially thought that the warning horn was the sound of the autopilot disengaging, but realised that was not the case as soon as he heard the propeller noise increase. The first officer realised the situation, and immediately moved the power levers forwards of the flight idle gate.

During the short time that the aircraft’s power levers were in the ground beta range, both propeller speeds increased uncontrollably by over 300 revolutions per minute. 

The crew found no abnormal engine indications as a result of the occurrence and the flight proceeded normally to Weipa. Subsequent maintenance checks after the flight did not reveal any engine or propeller system damage.

The aircraft design included features to reduce the likelihood of the power levers being moved into the ground beta mode during flight. However, the ATSB found that many DHC‑8-100, -200 and -300 series aircraft did not have any way of preventing movement of the power levers below the flight idle gate in flight, or a means to prevent such movement resulting in a loss of propeller speed control. This design limitation has been associated with several safety occurrences. 

As of March 2012, there were 57 DHC-8-100, -200 and -300 series aircraft registered in Australia. Some of the aircraft were acquired second-hand from the US and had protective measures previously installed as required by US airworthiness requirements. The ATSB contacted the DHC-8 operators and determined that, at the time of this occurrence, there were 52 aircraft in Australia that were not protected against the consequences of a flight crew moving the power levers below flight idle in flight.

The aircraft manufacturer has advised that it will be releasing a Service Bulletin modification to fix the propeller speed control issue. That bulletin will be mandated by an Airworthiness Directive from the airworthiness authority of the State of Design (Canada) to ensure that the bulletin is incorporated into all the aircraft affected by the design issue worldwide, including those in Australia. In addition, the aircraft operator has introduced a series of actions to reduce the risk of such occurrences. 

The ATSB found that while the beta warning horn sounded as designed, the pilots were not acutely aware of the purpose of the warning horn due to a lack of previous exposure to the sound. In response, the ATSB has released an extract from the cockpit voice recorder with the beta warning horn sounding and the audible rise in propeller speed evident to all Australian operators of the aircraft type. The audio file is also available on the ATSB website to help increase awareness of the issue.

Read the final report: Double propeller overspeed involving Bombardier DHC-8, VH-SBV, near Weipa, Queensland, on 6 December 2011, which provides the full report and the sample of the cockpit sounds.

A new booklet released by the ATSB today dispels the myth that experience will always protect pilots from an accident.

A new booklet released by the ATSB today dispels the myth that experience will always protect pilots from an accident.  

The booklet Experience won’t always save you: Pilot experience is not always a protection against an accident, is the latest release in the ATSB’s well-received Avoidable Accidents series.  

“There’s a reverence for those who have been flying a long time,” said Dr Stuart Godley, the manager of the ATSB’s Research Investigations and Data Analysis. “We like to believe that they’ve got the right stuff, that they know themselves and their aircraft, and they can draw on their wisdom to keep themselves safe. There are many famous accidents where it appears that pilot experience has made all the difference.”

These were experienced pilots
who knew their business, but it wasn’t enough to keep them safe.

 “However, a closer analysis of these accidents suggests that things other than experience alone have always also played a significant part in saving the day,” continued Dr Godley, “but they tend not to be emphasised in anecdotes and media.”

“On the other hand, fatal outcomes can and do happen to very experienced pilots, leading to questions of how could such a thing happen to someone with so much flying behind them.”

In creating this booklet, the ATSB has drawn on its investigation archives of 20 years to find case studies that illustrate how a fatal accident can happen to anyone, even those who have been flying for years. These examples cover a range of operations and aircraft types, and each one analyses the accident, breaking down the decisions and factors that contributed to the final, fatal result. 

“These were experienced pilots who knew their business,” said Dr Godley, “but it wasn’t enough to keep them safe.”

In some of these occurrences, very experienced pilots were undertaking flying that involved much higher risk. It turned out that their flying experience alone was unable to help them avoid disaster. Other accidents involved experienced pilots who may have allowed factors other than their experience to influence their actions. In other examples, the pilot’s vast experience may have even led to decisions that, in hindsight, were associated with more risk than necessary.

As with all the Avoidable Accidents booklets, Experience won’t always save you is available for free. “The book can be downloaded from the ATSB website or we’re happy to mail free copies to anyone who would like them,” said Dr Godley. “We’ve had excellent feedback on these publications—they’re a useful resource to anyone involved in flying, but we feel that this newest booklet is especially important. The issues that it examines are something that all pilots need to think about and take into account.”

Please send requests for copies of the booklet via email to atsbinfo@atsb.gov.au 

The ATSB has released a new aviation bulletin featuring nine investigation reports. The Aviation Short Investigation Bulletin Issue 15 presents short, office-based investigations conducted over the past nine months.

The Australian Transport Safety Bureau has released a new aviation bulletin featuring nine investigation reports. The Aviation Short Investigation Bulletin Issue 15 presents short, office-based investigations conducted over the past nine months. 

The bulletin covers incidents and accidents involving turboprop piston aircraft, and helicopters. None of the accidents were fatal; however, some of the aircraft sustained 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:

• Aircraft proximity event between Beech 1900, VH-EMK and Airparts FU-24, VH-HVP  (AO-2012-134)
• Weather balloon event involving Bombardier DHC-8-400, VH-LQG (AO-2012-144)
• Runway excursion involving Piper PA-39, VH-MMN (AO-2012-145)
• Wheels up landing involving Beech A36, VH-SQI (AO-2012-151)
• Landing on a closed airstrip involving a Piper PA-28R, VH-HKZ (AO-2012-155)
• Ditching involving Robinson R44, VH-CYH (AO-2012-096)
• Power loss involving Robinson R44, VH-NWD (AO-2012-136)
• Hard landing involving Cabri G2 VH-CDU (AO-2012-140)
• Controlled flight into water involving Robinson R22, VH-HOA (AO-2012-146)

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 15

ATSB welcomes the reappointment of Ms Carolyn Walsh as a member of the ATSB Commission.

The Australian Transport Safety Bureau (ATSB) welcomed the reappointment of Ms Carolyn Walsh as a member of the ATSB Commission. Ms Walsh’s appointment by the Minister for Infrastructure and Transport, the Hon Anthony Albanese will commence on 8 March 2013 and will run for a further three years.

Ms Walsh has a wealth of experience in the field of transport safety in both policy and regulatory roles. She has specialist expertise in safety (both transport and occupational health and safety), risk management and the regulatory framework governing transport operations in Australia.  She was the Chair of the national steering committee that advised the National Transport Commission on the development of the national Model Bill for Rail Safety.  

Before becoming a Commissioner of the ATSB Ms Walsh was the Chief Executive of the NSW Independent Transport Safety and Reliability Regulator. She is currently a member of a number of Audit and Risk Committees for NSW Government agencies including: Aboriginal Lands Council (Chair), Information and Privacy Commission (Chair), Police Integrity Commission (member) and Office of the Director of Public Prosecutions (member).

The ATSB’s Chief Commissioner, Martin Dolan, said that he welcomes the opportunity to continue working with Ms Walsh to advance the national transport safety agenda. 

The ATSB urges pilots to take the time to ensure they have all the information they need before landing their aircraft.

The Australian Transport Safety Bureau urges pilots to take the time to ensure they have all the information they need before landing their aircraft. This warning comes after an accident in South Australia where a Piper PA-39 skidded off the end of the runway at Innamincka, before spinning to the left and coming to rest in a gully.

The aircraft was carrying the pilot and one passenger. The landing area at Innamincka had one gravel runway, about 1,000 m long. As the aircraft approached the airfield, the pilot noticed that the windsock was indicating a strong crosswind. As a precaution, he increased his approach speed and reduced his flap setting. The pilot elected to land further along the runway than normal to avoid the rough, rocky ground just before the runway. As a result, the aircraft touched down about a quarter of the way along the runway.

Pilots should establish a decision point along the runway at which a go-around should be initiated if the requirements for a safe landing can no longer be met.

When the aircraft was about halfway along the runway, the pilot realised that it was going too fast, so he applied full braking. He judged it was too late to commence a go-around, but the braking was ineffective due to the surface of the runway. The aircraft continued on beyond the end of the runway before its left wheel struck a depression. This caused it to spin to the left before coming to rest in a one-metre-deep gully. The pilot sustained minor injuries and the passenger was uninjured, but the aircraft was significantly damaged. The pilot recalled the surface of the runway contained a lot of small loose stones, which may have affected the braking capacity of the aircraft during the landing.

This accident demonstrates the importance of assessing the operational and environmental conditions at the time to determine the most suitable landing type. Pilots should also establish a decision point along the runway at which a go-around should be initiated if the requirements for a safe landing can no longer be met.

The accident also highlights the benefits of using all available resources, including people on the ground, for gathering information on the actual conditions.

Read the final report: Runway excursion involving Piper PA-39, VH-MMN, Innamincka Township (ALA), South Australia, on 26 October 2012, which contains links to publications on short field approaches and landings.