On 27 July 2015, the pilot of an Eagle DW1 aircraft, registered VH-FHP, was conducting aerial spraying operations on a property about 77 km southeast of Townsville, Queensland. The pilot completed aerial spraying of two paddocks, and then loaded the aircraft with about 450 L of chemical (about half capacity), and half a tank of fuel.
At about 0930 Eastern Standard Time (EST), the pilot took off to spray the third paddock for that day. The pilot overflew the paddock and identified two sets of powerlines. The pilot formed a plan to spray the paddock using a racetrack pattern and flying it in a clockwise direction. One set of powerlines ran parallel to the spray direction, and the other ran across it at the western end. There was a line of trees along the western powerline, which obscured vision of the power poles.
The pilot completed the first spray run towards the western powerline, overflew it, and then turned to line up for the second spray run (Figure 1). A small area of about 30 m of trees had been cleared for a pump installation and the clearing was in line with the start of the second spray run. The pilot noted the powerline ahead, but then diverted their attention to the other powerline, running parallel to the direction of flight, and about 5 m off the left wingtip. The pilot also looked inside at the GPS to check the aircraft’s line for the spray run.
Figure 1: Paddock to be sprayed showing powerlines and wirestrike location
Source: Google earth and the pilot of VH-FHP – annotated by the ATSB
The pilot commenced the descent into the paddock through the clearing in the trees and did not see the powerline at that time. As the aircraft descended, the pilot looked up and suddenly sighted the powerline. The pilot elected to push forwards on the controls to make the aircraft descend. The aircraft then struck the powerline above the propeller on the wing struts.
After the aircraft struck the wires, it yawed violently to the left. The pilot used the right rudder to turn the aircraft away from the other powerlines, and the force of the aircraft pulled the transformer off the power pole on the left. The aircraft then yawed to the right. The force broke the power pole on the right and severed the powerline.
The aircraft decelerated rapidly, and the wires pulled the aircraft towards the ground. The pilot landed the aircraft with the wings level. The landing gear sheared off, the propeller struck the ground and the aircraft ground-looped, coming to rest facing the opposite direction. The pilot sustained minor injuries and the aircraft was destroyed (Figure 2).
Figure 2: VH-FHP at the accident site showing damage to the aircraft and wires
Source: Aircraft operator
Pilot comments
The pilot provided the following comments:
The pilot had sprayed that paddock once previously, and had used an anticlockwise racetrack pattern. On that occasion, as the power poles were on the eastern side of the trees, they were more visible from that direction.
The pilot elected to descend after sighting the powerline, to prevent the landing gear from potentially catching on the wires and flipping the aircraft over.
The aircraft had a wire cutter on the undercarriage and a wire deflector between the top of the wing and the tail, but not on the struts where the wire struck.
The powerlines were three phase.
Safety message
The pilot was aware of the powerline the aircraft collided with, but did not have it front-of-mind at the start of the spray run. The pilot’s attention was diverted to other powerlines, parallel to the direction of flight, and also inside the aircraft to the GPS. The pilot reported that stating aloud ‘powerlines ahead’, would have helped to maintain awareness of the wires.
The Aerial Agricultural Association of Australia suggests a way to keep focus is to ask yourself:
Where is the wire now?
What do I do about it?
Where am I in the paddock?
For further risk management strategies for agricultural operations, refer to the Aerial Application Pilots Manual.
The ATSB research report Aerial application safety: 2014-2015 year in review, stated that aerial application operations have a high accident rate relative to other aviation sectors. These operations involve inherent risks. Those risks include low-level flying, high workloads and obstacles such as powerlines. More than half of the total accidents and serious incidents over the past 10 years were wirestrikes.
The report also stated that it is important to constantly monitor the environment, so the hazards that were identified in pre-planning can be recognised and avoided. If a pilot is not specifically looking for a hazard, it is unlikely they will notice it.
The ATSB investigated a similar accident, involving a Robinson R66 helicopter. A copy of that report is available here: AO-2014-142.
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, a limited-scope, fact-gathering investigation was conducted in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Ownership of intellectual property rights in this publication
Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia.
Creative Commons licence
With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence.
Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work.
The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau
Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
On 24 July 2015, container freight train 6MC2 lost two containers from the train as it passed through Bowser, north of Wangaratta. The two containers lost from the train landed clear of the track on the eastern side. The train continued its journey with the crew unaware of the incident.
At about 0430 the following morning, the driver of another freight train noticed a container and reported it to train control.
What the ATSB found
The ATSB found that it was very likely that the twist locks that secured the containers to the train were ineffective prior to the incident. This condition allowed the unsecured containers to fall from the train. It is probable that strong winds contributed to the movement of the unsecured containers. Other external forces, such as train and track dynamics, may have also contributed to the movement. However, there was no evidence of such contribution.
Given the containers were located some distance behind the locomotives, and that no other train operational systems were affected when they fell from their respective wagons, the train crew were not aware of the incident.
What's been done as a result
As a result of the incident, Pacific National undertook an internal investigation into the incident and has taken action to:
initiate a process to include checks for twist lock operation as part of wagon maintenance and inspection
develop a twist lock inspection manual
update freight loading manuals to include methodology for identifying defective twist locks
update wagon maintenance manual to include methodology for identifying defective twist locks
update twist lock training materials to include identification of defective twist locks
initiate a review of twist lock integrity history
initiate a review of twist locks currently in service – supply and type
calculate the failure rate of twist locks across the Intermodal fleet for probability and risk mitigation considerations.
Safety message
Rail operators should satisfy themselves that their procedures can ensure that all twist locks are effective at securing freight containers to their respective wagons before the transit of trains.
The occurrence
At about 1428 on 24 July 2015, container freight train 6MC2 departed Appleton Dock, Melbourne headed for Griffith, New South Wales. The train was programmed to detach wagons at certain locations along the standard gauge route. Train 6MC2 was owned and operated by Pacific National (PN). The train consisted of three locomotives (two were off line) hauling 60 wagons, was 1272 m long, with a total mass of 2051 t. The train was a scheduled service, transporting containers between Melbourne and Griffith.
At about 1805, train 6MC2 passed through Wangaratta travelling on the east track. A short time later near Bowser (North Wangaratta), the train passed V/Line passenger train 8630 on the west track heading to Melbourne. A little further on, the train crew noticed the trees alongside the track swaying violently in a localised storm event. The crew commented that the wind swayed the locomotive. At this point, unbeknown to the train crew, two containers fell off the train.
The train continued on its programmed journey towards Griffith. At Ettamogah, 13 wagons were detached, but the missing containers were not noticed.
At about 0430 on 25 July 2015, the driver of freight train 3PW4 (travelling on the west track) sighted a shipping container lying next to, but clear of, the east track between Wangaratta and Springhurst at the 244.500 track km point. The driver reported the container to the Australian Rail Track Corporation (ARTC) Network Control Centre South located at Junee, New South Wales. The ARTC network control centre warned another following train, XPT passenger train ST21 travelling from Sydney to Melbourne on the east track, to proceed at caution. At 0447, the driver of ST21 confirmed the details and location of the container with the ARTC network control centre.
Figure 1: Containers laying adjacent the track
Note: The blue container in the foreground was located on the 17th wagon. The red container in the background was located on the 13th wagon. The direction of travel shown with a red arrow. Source: Pacific National
The ARTC arranged to have the track inspected. At about 0634, the inspector arrived on site and discovered a second shipping container near the track. Both containers were clear of the track and normal train running resumed.
The ARTC established that the containers had fallen from train 6MC2 the previous night. By then, seven trains had passed the location since the containers were lost from train 6MC2. Of the seven passing trains, five were on the West track and two on the East track.
Safety analysis
Twist locks
Containers are loaded onto suitable rail vehicles and secured at each corner by twist locks. Pacific National’s Freight Loading Manual[1] (FLM) details specific requirements for securing containers to wagons. The manual specifies:
All devices used to secure containers to rail wagons must be in a sound and serviceable condition.
All containers MUST have all four securing devices locked in position prior to transit.
There are four types of approved securing devices:
Portable twist locks (automatic operation)
Portable twist locks (manual operation)
Portable anchor brackets
Internal hook type
External clamp type
Retractable fixed twist locks
Hinged type
Pop up type
Patrick Port Logistics (PPL) loaded the two containers that subsequently fell from train 6MC2. PPL also had requirements[2] for securing containers to rail wagons. These requirements largely reflected the Pacific National (PN) specific requirements. On the day of the incident, PPL used eight automatic twist locks, one on each corner, securing both containers to the rail wagons. PPL used a combination of two Gavan, one Celtec Cel-Lock TFA, and five Celtec Cel-Lock TFAD twist locks, Figure 2 and Figure 4.
Figure 2: Twist lock types
Source: Pacific National
The normal position of an automatic twist lock is in the locked position, Figure 3. When a container is loaded onto a rail wagon the container pocket unlocks the twist lock head. When the container is fully seated, the twist lock head returns to the locked position, securing the container. When a container is unloaded, the lifting action applies sufficient force to unlock the twist lock head and releases the container.
If a twist lock sticks, operators can release the lock manually. Twist locks are fitted with an emergency release pin and/or a visual safety indicator. Once released manually, operators must manually reset before the next use. Loading staff can visually inspect these indicators (indicator and/or pin) to ascertain the state of the twist lock.
Figure 3: Twist lock engagement
Note: Celtec TFAD type twist lock showing unlocked and locked positions. Source: Celtec.
Following the incident, PN found the twist locks still fastened to the rail wagon. One lock was broken and all others were in the unlocked position, as shown in Figure 4.
Figure 4: Twist lock layout as found
Note: Based on ‘as found’ condition by PN.
Twist lock inspection
Following the incident, Pacific National commissioned a report to investigate the condition of the twist locks. A specialist inspected the twist locks from both wagons to determine the serviceability of them. The report notes:
All but one twist lock was in open position when collected. 2 X Gavan + 1 X first generation Celtec TFA had broken Emergency Release (See new design Celtec TFAD and TFAE how the house is designed so that ER is not exposed to impact as much as the old TFA). 2 X Celtec TFAD could be returned to activated position. 1 X Celtec TFAD had a broken shaft. The twist locks should not have been in use as they were not activated or could not be activated…
It is concluded that containers MAGU5655514 and MRKU8741873 were able to break free from their respective wagons due to twist locks being in poor condition rendering them completely ineffective.
Based on the condition of the twist locks, and supported by the specialist report, it is very likely that the twist locks were not working prior to the incident. This condition allowed the containers to fall from the train. Given the distance behind the locomotives, dark light condition, and that no other train operational systems were affected, the train crew were not aware of the incident.
Furthermore, the generally poor condition of the twist locks, including serviceability, was not detected particularly during the pre-loading, or post loading inspections. Before loading, twist locks must be inspected for serviceability before use. Any unserviceable twist locks are quarantined from further use until repaired. After loading, the twist locks are not specifically checked during pre-departure or in-service inspections. Although the FLM provides guidance on pre-loading inspection of twist locks, there is no other guidance available to perform adequate post-loading inspections.
At no stage were the defective twist locks identified. In this case, allowing ineffective twist locks to enter service affected the safe transit of the train.
Environmental conditions
Both drivers of train 6MC2 commented on abnormal weather conditions north of Wangaratta. The conditions were such that the leading locomotive was shaken as debris was blown across the track.
Weather station data was obtained from the Bureau of Meteorology (BOM) located at Wangaratta aero, about 12 km from the incident site. At 1500, on the day of the incident, the temperature was recorded as 11 °C, 99 per cent relative humidity, and wind from the north at 13 km/h. In addition, data was obtained from a local council weather station at Bowser, about 6 km from the incident site. At the time of the incident, this data recorded the temperature as 12 °C, 94% relative humidity, and wind from the southwest at 17 km/h.
Notwithstanding the weather data, the train crew witnessed a weather event. Based on the proximity of the Bowser weather station, the event was most likely localised. The local council had no reports of storm damage.
Weather effect on train 6MC2
The Rail Industry Safety and Standards Board (RISSB) provides guidelines[3] on calculating wind force on railway vehicles. These guidelines were used to determine minimum wind force needed to unlock twist locks (in good condition and effective) and blow the containers off the train.
Based on the characteristics of the wagons, a perpendicular wind speed in excess of 160 km/h would be needed to apply sufficient lifting force to unlock the twist locks and tip the containers off. There is no evidence of a weather event in that location generating wind speeds in excess of 160 km/h.
Summary of environmental conditions
There was no evidence that environmental conditions existed that were severe enough to tip containers, if secured by effective twist locks.
However, considering the post incident condition of the twist locks in this case, it is probable that the weather witnessed by the train crew contributed to the movement of the unsecured containers (Figure 5). Other external forces, such as train and track dynamics, may have also contributed to the movement however, there was no evidence of such contribution.
Figure 5: Wind affect
Related occurrences
The Office of the National Rail Safety Regulator (ONRSR) maintains a database of occurrence events reported. A review of that database for the previous 12 months showed 28 reported instances of containers found with ineffective twist locks in service.
Based on this data, it is not uncommon to find ineffective twist locks in service. Although the container remained on the rail vehicle in most instances, the risk of loss still existed.
Findings
From the evidence available, the following findings are made with respect to the loss of containers from train 6MC2 near Bowser, Victoria, on 24 July 2015. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing factors
A localised weather event probably shifted the inadequately secured containers from the wagon.
The twist locks were in an unserviceable condition meaning that they did not engage during loading. The containers were not adequately restrained during transit.
Pacific National had documented instructions for pre-loading inspections, but in this case the poor condition of the twist locks was not detected.
Pacific National did not have any documented instructions requiring post-loading inspection for twist lock effectiveness.
Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.
Pacific National
As a result of the incident, Pacific National undertook an internal investigation into the incident and completed the following actions:
initiate a process to include checks for twist lock operation as part of wagon maintenance and inspection
develop a twist lock inspection manual
update freight loading manuals to include methodology for identifying defective twist locks
update wagon maintenance manual to include methodology for identifying defective twist locks
update twist lock training materials to include identification of defective twist locks
initiate a review of twist lock integrity history
initiate a review of twist locks currently in service – supply and type
calculate the failure rate of twist locks across the Intermodal fleet for probability and risk mitigation considerations.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, a limited-scope, fact-gathering investigation was conducted in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Ownership of intellectual property rights in this publication
Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia.
Creative Commons licence
With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence.
Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work.
The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau
Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
On the afternoon of 26 July 2015, the pilot prepared a PA32-300 (Cherokee Six) aircraft, VH-BDG (BDG), for a private joy flight around the Whitsunday Islands off the Queensland coast, (Figure 1) departing from the Lakeside Airpark. The pilot had arranged for five acquaintances to come on the flight as passengers.
About a week earlier, the pilot, who had an injured right foot at the time, organised another pilot to fly BDG on a re-positioning flight to the Lakeside Airpark. Due to being unable to fly the re-positioning flight, the accident flight became the pilot’s first time operating from the Airpark.
Pilot recollections
The pilot reported that they delivered a safety brief outlining the relevant safety features of the aircraft, just prior to loading the passengers. After loading the four rear passengers, the pilot secured the left rear cargo door, and then entered the cockpit through the front right door, followed by the front seat passenger.
The flight departed at about 1400 Eastern Standard Time (EST), and remained outside controlled airspace. The flight overflew some of the Whitsunday Island group as well as the outer reef area of the Great Barrier Reef, prior to setting a return course to the Airpark about one and half hours later (Figure 1).
Figure 1: A google earth extract showing the general area where the joyflight was conducted
Source: Google earth, annotated by the ATSB
The pilot approached the extended centreline at an oblique angle and conducted a straight in approach to runway 22 (Figures 2 and 3). When about 6 NM from the airfield, at about 2,300 ft above mean sea level, the aircraft was configured for descent. After reducing the airspeed from about 135 to about 100 kt, and with 10° of flap selected, the aircraft descended to about 1,800 ft.
Figure 2: An extract from the Queensland Country Airstrip Guide. Diagrammatic representation of Lakeside Airpark and local hazards
Source: Queensland Country Airstrip Guide, 2012 edition
Figure 3: Approach to runway 22 at Lakeside Airpark. Note the unsealed and sealed portion of the runway. Also, note the difficulty in detecting the power lines on approach. Photo taken about a week prior to the accident
Source: Barry Dionysius
In order to maintain sufficient clearance over the two rows of power lines, and still land near the threshold, well before the sealed section of the runway, the pilot planned a steeper approach than normal. The flap was set to 40° (full flap) and the rate of descent increased to about 500-600 feet per minute.
On short final, the aircraft suddenly began to sink rapidly, and the pilot recalled seeing a tree pass close by the left window. Judging that the aircraft was now too low; the pilot applied full power, held the aircraft nose in a raised position, turned the aircraft left toward lower ground, and initiated a go-around.
However, the aircraft continued to sink throughout this manoeuvre, and the tail struck the runway about 20 m in from the threshold. Throughout this attempt to go-around, the tail continued to drag along the gravelled section of the runway, leaving a mark about 30-35° to the left of the runway direction for about 18m.
Although not yet showing a positive rate of climb, the aircraft seemed to be flying. The pilot reported that the stall warning had not sounded, so assessed there was a choice between removing the power and attempting to land back on the runway, or continuing with the go-around. The pilot elected to continue with the go-around and continued toward the lower ground.
A witness mark made by the right wheel, commenced at about the same spot where the mark made by the tail stopped. The wheel mark continued for about 35m into the grassed area beside the runway.
Once into the grassed area, and with the aircraft most probably airborne, it struck a wire fence (Figure 4) then the raised embankment of the dam, which ran perpendicular to the runway. The pilot reported that the left wing tip struck the water and the aircraft spun around and entered the water. At some point throughout this sequence, the main wheels detached from the aircraft. The pilot reported continuing to battle for control of the aircraft, up until it arrived in the water.
Figure 4: Looking along runway 22 taken a few days after the accident
Source: Pilot
Post water impact
When the aircraft settled on the surface of the water, the pilot reported yelling to the passengers to ‘get out’. The pilot then opened the front right door, pushed the passenger occupying the front right seat out, and then exited. The opening of the door resulted in the muddy water gushing inside and rapidly filling the aircraft. The passengers seated in the rear of the aircraft were unable to open the rear door. The water almost filled the entire cabin during this time.
The pilot was eventually able to get the rear door open from outside the aircraft and assisted some of the passengers out. The remaining passengers either made their own way out, or were assisted by other passengers.
One of the passengers sustained serious injuries, and the pilot and another passenger, minor injuries. The aircraft was almost completely submerged resulting in substantial damage (Figures 5 and 6).
Figure 5: Post accident showing VH-BDG partially submerged in the dam
Source: Airpark operator
Figure 6: VH-BDG after retrieval from the lake. Passenger 2 (below) reported that the left wing crumpled during the ‘cartwheeling’ toward the lake. Note:Significant damage occurred during the retrieval process
Source: Pilot
Pilot experience and comments
The pilot had approximately 581 total flying hours with about 112 of these on Cherokee Six type aircraft. The pilot made the following points:
the hazard briefing conducted by the airpark operator some weeks earlier, included a request to land on the gravel area of the runway, as the seal was recently laid but had proved to be quite soft
both weight and balance, and performance calculations were conducted for the flight, however these documents were damaged when the aircraft became submerged
there may have been some wind shear or a down draft which contributed to the aircraft sinking on the approach
the tail scraping along the gravel and over the fence during the attempted go-around added extra drag, which detracted from the aircraft’s performance
Passenger comments
Three of the five passengers elected to provide their accounts of what happened.
Passenger one recalled:
there was no pre-flight safety briefing; the pilot just indicated where each of them should sit
during the landing approach, this passenger recalled thinking how low they were, when still some distance from touchdown
the tail struck the ground, and recalls power being applied after that
the aircraft flipping over and ‘cartwheeling’ toward the lake
Passenger two recalled:
there was no pre-flight safety briefing
during the approach to land they heard the pilot verbalising that the aircraft needed to slow down, and noted a significant decrease in speed
the aircraft tail dragging along the ground, and the pilot calling out for assistance
the left wing striking the ground and instantly crumpling (Figure 6)
the aircraft then ‘cartwheeled’ ending up in the lake
the water rose quickly in the aircraft when the front door was opened, leaving a very small pocket of air for the rear passengers
they were rescued by the pilot through the rear door
Passenger three recalled:
there was no pre-flight safety briefing
the aircraft struck the ground prior to the runway
the pilot shouted for assistance as the aircraft “went out of control during the approach”
the aircraft ‘cartwheeled’ before arriving in the dam
Meteorological data
The ATSB obtained the Bureau of Meteorology weather report for area 44 covering the time of the accident. Area 44 was in two divisions that day and the southern division, which applied to the area south of Proserpine, including Lakeside Airpark, forecast variable winds of about 10 knots.
Lakeside Airpark landing area
Lakeside Airpark Landing area was identified in Enroute Supplement Australia (ERSA) (28 May 2015 version) as “UNCR” meaning it is both uncertified and unregistered.
As per the requirement for operations at this aerodrome, the pilot sought prior permission to operate there and a briefing on local hazards from the aerodrome operator. This onsite briefing by the aerodrome operator pointed out local hazards such as the powerlines in the vicinity and the preferred protocol of taking-off on runway 04, and landing uphill on runway 22, wind permitting. There was no hazard map available as mentioned in the ERSA.
Advisory material
The Civil Aviation Advisory Publication (CAAP) 89O-1 (2) “Published aerodrome information andreporting changes (November 2000) is available on the CASA website. This publication provides advisory material for publishing aerodrome information and reporting changes in respect of both licenced and unlicensed aerodromes that are included in the (ERSA).
Unlicensed aerodromes:
Unlicensed aerodromes are not required, under the regulations, to provide aerodrome information to [Aeronautical Information Service] (AIS) or the [Civil Aviation Safety Authority] (CASA) and to have their aerodromes included in ERSA.
…unlicensed aerodromes may also be included in ERSA, on request of the aerodrome operators. However, the aerodrome information published will be of limited format, being of a non-operational nature…”
CASA is conducting a post-implementation review of CASR Part 139 – Aerodromes. As part of this project, this CAAP and other Part 139 CAAPs and ACs will be reviewed. Additionally, CASR Part 175, which regulates the publication of aeronautical information, commenced on 5 March 2015 and the contents of CAAP 89O-1 (2) will be reviewed, to be consistent with this new regulation.
ATSB comment
The ATSB did not undertake an onsite investigation into this accident, but were provided with information through telephone interviews, reports, and detailed photographs.
The ATSB was unable to reconcile the differences evident between the recollections of the pilot and those of the three passengers who provided information.
Safety message
This accident highlights the importance of thorough pre-flight planning and preparation to minimise safety critical decisions in flight.
CASA have an online kit ‘CASA Flight Planning Always Thinking Ahead” available from the downloaded from the CASA website.
This tool kit addresses the three levels of flight planning (the straightforward elements, unusual situations and whether to go) and their application over eight stages of flight.
The ATSB research report, Improving the odds: Trends in fatal and non-fatal accident in private flying operations(AR-2008-045) is available from the ATSB website.
This report encourages pilots to make decisions before the flight, continually assess the flight conditions, evaluate the effectiveness of their plans, set personal minimums, assess their fitness to fly, and to seek local knowledge (and if necessary a check flight) on the route and / or destination as part of the pre-flight planning process.
Also on the ATSB website, is a copy of the investigation (199804109) into a fatal accident involving another Cherokee Six aircraft (VH-POW). The pilot attempted to conduct a go-around from a degraded performance configuration with full flap extended and a nose-high attitude. The ATSB found that the aircraft's climb performance would have been substantially degraded with this configuration. The aircraft's nose-high attitude during the climb would have obstructed the pilot's forward vision and he may have been unaware that the aircraft had diverged from the extended centreline of the airstrip.
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, a limited-scope, fact-gathering investigation was conducted in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Ownership of intellectual property rights in this publication
Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia.
Creative Commons licence
With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence.
Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work.
The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau
Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
The pilot joined the circuit on downwind leg for runway 27. The wind was observed on the windsock to be swinging from south through to southwest. It was reported as 180/11 on the ATIS. On short final, full flap was selected and the speed reduced to 65 knots. As the pilot initiated the flare the aircraft encountered a wind gust which displaced it to the right of the sealed runway.
The pilot recovered but then encountered another gust which caused the right wing to drop. He applied full power to go around and got the wings level, but the aircraft then hit the ground hard on all three wheels with full power still applied. The nosewheel dug into the dirt and broke off. The aircraft then nosed over onto its back.
Factors
The following factors were considered relevant to the development of the accident:
1. The aircraft was affected by significant wind gusts at a critical stage during landing.
2. The pilot was unable to recover the aircraft from the effects of the wind gusts.
The captain reported that at flight planned optimum cruise altitude the aircraft failed to meet expected cruise performance. When the aircraft arrived at Perth a re-weigh of the payload was requested. The re-weigh showed that the payload was approximately 3500 kg more than was indicated on the loading documentation. This meant that the aircraft had been operated at weights in excess of its maximum zero fuel weight and maximum brakes release weight.
The investigation revealed that four unrelated factors had contributed to the overloading of the aircraft.
The first involved accepting freight from another air freight company on the basis of the weights provided by that company and not re-weighing the freight to check the weights.
The second involved weighing freight on scales with which the airfreight personnel were not familiar and not properly positioning the freight trolleys on the scales.
The third involved a communication breakdown between loading personnel which resulted in freight being loaded on the aircraft that was not included in the loading documentation.
The final factor was minor in nature and involved last minute removal and addition of freight from/into containers without accurate adjustments being made to the loading documentation. The company has addressed these problems and taken corrective action to prevent a recurrence.
The helicopter was being used to evacuate a workman from an outstation due to flooding in the area. The pilot, concerned about the deteriorating weather conditions, decided to add another 10 litres of fuel from a drum located at the outstation. The pilot reported that he checked the fuel tank drain finding no indication of water or contamination.
About 30 seconds after take-off the engine began to misfire badly and lose power, committing the pilot to a near vertical autorotational landing into a small hole in the relatively high timber. The autorotation was commenced from about 150 feet above ground level at about 30 knots airspeed, with a turn of 90 degrees required to reach the small clearing. The pilot was unable to reduce the subsequent high rate of descent even though full up collective pitch was applied from about 8 feet above the ground.
This resulted in a heavy landing causing substantial damage to the helicopter. Investigation revealed that the aircraft fuel system was contaminated with water.
On arrival in the circuit area at Cooinda the pilot selected the landing gear down but no 'down' indication was obtained for the left main gear. After several unsuccessful attempts to obtain a left gear down indication, the pilot decided to return to Jabiru where company ground staff were available.
He contacted Adelaide Flight Service with a request to telephone his company but did not advise of any problems with the aircraft. At Jabiru several normal and emergency extensions of the landing gear were carried out, each time with the same unsafe indication. Several passes were flown to enable ground staff to confirm the position of the landing gear, which appeared to be down.
A normal approach and landing was made but as the aircraft touched down the left landing gear leg collapsed. The pilot was able to hold the wing up for a short time, but as the aircraft slowed the left wing settled onto the runway, turning the aircraft through 180 degrees. Because the pilot had not advised Adelaide Flight Service of the problem the aerodrome emergency procedures were not activated.
Subsequent investigation revealed that the left hand extension/retraction mechanism torque tube rod attachment had failed due to fatigue.
VH-TJM departed Ayers Rock for Alice Springs and VH-LTC departed Alice Springs for Ayers Rock. To ensure separation the Alice Springs air traffic controller assigned a cruising altitude of 5000 feet to VH-LTC and cleared VH-TJM to descend to 7000 ft. He estimated that the aircraft would pass about 40km from Alice Springs and VH-LTC was instructed to report sighting and passing VH-TJM.
Subsequently, at 48km from Alice Springs, VH-TJM was cleared for a visual descent. The air traffic control workload was heavy at the time, but shortly afterwards the controller realised he had not applied a separation standard before allowing VH-TJM to commence the visual descent. He contacted both aircraft for position reports which revealed that they had passed safely and were about 20km apart. Fortuitously there was no confliction.
The pilot had not flown the aircraft type (a single seat machine) previously and was checked by the owner prior to commencing the flight. The glider was to be launched by being towed behind a powered aircraft. The pilot reported that the ground run was normal but after the glider became airborne it immediately climbed above the slipstream of the tug aircraft. The glider then descended below the slipstream and the pilot applied back stick to climb but the tail struck the ground.
The tail section broke off and the glider climbed before nosing down and impacting the ground. It rolled over after impact and the pilot sustained serious back injuries. The glider was a relatively high-performance type and is reported to be susceptible to pilot induced oscillations, particularly after take-off. The pilot had begun flying again in 1993 after a 10-year break.
Since recommencing flying, she had accumulated some 30 hours, of which only 2.5 were on single seat fibreglass types. The gliding club chief flying instructor was of the opinion that the pilot should have spent more time in other single seat gliders before attempting to fly this particular type.
After completing a sequence of touch and go circuits the aircraft returned to the parking area. The pilot was performing a pre-shutdown hydraulic pressure check when he inadvertently selected the landing gear to the UP position and the nose gear retracted. Investigation determined that the landing gear selector ground safety lock was out of rig and allowed the selector to move to the UP position whilst the aircraft was on the ground.
